Please enable JavaScript in your browser to complete this form.* indicates a required field Please choose yes or no for each optionLactation, Pregnant *YesNoSelf-Tanners, beach vacation or tanning, including tanning beds seven days before and seven days after treatment. *YesNoTattoos covering the full treatment area *YesNoFor face-use of Accutane in the last six month *YesNoHistory of high blood pressure *YesNoCardiac pacemaker, defibrillator or electronic device/metallic implant *YesNoUse of immunosuppressive medication (affecting the autoimmune system) *YesNoDeterioration of the immune system (such as AIDS or HIV) *YesNoActive or recent malignant pathology (cancer) *YesNoActive or recent malignant pathology (cancer), use of anti-cancer drugs or precancerous lesions or suspicious moles *YesNoUncontrolled endocrine disorder (diabetes, thyroid, hormonal or polycystic ovaries) *YesNoHepatitis or liver disease *YesNoEpilepsy *YesNoCoagulopathy, excessive bleeding (hemorrhages), hematomas *YesNoUse of anticoagulant medication *YesNoHistory of deep vein thrombosis in the treatment area *YesNoHistory of photosensitivity or use of medication that increases the photosensitivity of the skin between 6 months and 1 year prior to treatment, or herbs (St. Johns Wort) 2 weeks prior to the treatment. *YesNoVitiligo or a tendency towards hypopigmentation *YesNoTendency towards keloid formation or deterioration of the healing process. *YesNoHistory or evidence of any chronic or recurring skin disease or disorder. *YesNoPatient Signature *By Signing above, I acknowledge that I have read all the details in the above consent form and will receive a copy of this form in email after it is signed. Clear Signature Patient Full Name *Date *Patient Email *Patient Phone Number *WebsiteSubmit