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Medical History

Medical HistoryRocky Mountain Skin Care2020-02-14T02:34:21+00:00

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  • Personal History

    In order to provide you with the most appropriate treatments, we need you to complete the following questionnaire. All information is strictly confidential and secured.
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  • Date Format: MM slash DD slash YYYY
  • Medical History

    (Please check all that apply)
    (Please check all that apply and describe the reaction you experienced)
  • Medications

  • Procedure History

  • For Our Female Clients

  • Informed Consent For Removal/Reduction of Brown Spots & Spider Veins

  • Treatment sites: mono-brow, lip, chin, neck, face, arms, fingers, chest, areola, linea, underarms, back, buttocks, bikini, labia, scrotum, thighs, lower legs, feet, and toes.

    The purpose of this procedure is to diminish or remove unwanted hair. The procedure requires more than one treatment and may produce permanent hair removal. The total number of treatments will vary between individuals. On occasion there are patients that do not respond to treatments. The treated hair should exfoliate or push out in approximately 2-3 weeks.

    Alternative methods are waxing, shaving, electrolysis, and chemical epilation.

    The following problems may occur with the hair removal system.

    1. There is a risk of scarring.

    2. Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation (browning) and Hypo-pigmentation (lightening) have also been noted after treatment. These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Avoiding sun exposure before and after the treatment reduces the risk of color change.

    3. Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.

    4. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.

    5. Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. Systemic reactions (which are more serious) may result from prescription medicines.

    6. I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.

    7. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.

    Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

  • Informed Consent for Hair Removal

  • I authorize Valerie Snaldome, experienced and trained in the removal of brown spots and superficial spider veins, to perform the procedure. The light pulsed system will dramatically reduce darkly pigmented sunspots and spider veins. More than one laser session may be necessary to achieve desired results. However, other treatments, including skin care products, are often needed to blend color, reduce sun damage, and give the best results. The FDA has given the clearance for removal of brown spots, spider veins, and rosaccea.

    The skin treated will be red and swollen with fine, thin scabs forming. Please keep the treated areas covered with Polysporin and Aquaphor until the thin scabs fall off. This process will take anywhere from 1-3 weeks. It could take as long as 3-6 months in some cases. Do not scratch the scabs, which can cause scarring.

    We are unable to treat clients that are on ACCUTANE, and PHOTOSENSITIZING medications. Clients using ANTICOAGULANTS should be noted.

    The following problems may occur with treatment:

    1. Scarring: The light pulsed system can create a bruising and a moderate burn or blister to the skin. For an effective treatment, the power (joules) needs to be just below the blistering point which means skin will be red. Although it is certainly possible to scar with a burn or blister, it has not been a problem with the Medilux. However slight, there is a risk of scarring.

    2. Hyper-pigmentation (browning) and Hypo-pigmentation (whitening) have been noted after treatment, especially with a darker complexion. This usually resolves within weeks, taking as long as 3-6 months in some cases. Permanent color change is a rare risk. If you have a lot of color in your skin, a skin lightening cream will be advised to reduce the melanin in your skin before the treatment. Avoiding sun exposure after the treatment reduces the risk of color change.

    3. Infection: Although infection following pulsed light treatment is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a laser treatment. This applies to both individuals with a past history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatment including antibiotics might be necessary. If you have a history of herpes simplex virus in the treated are we would recommend preventative therapy.

    4. Bleeding: Pinpoint bleeding is rare but can occur following brown spot and spider vein treatment procedures. Should bleeding occur, additional treatment might be necessary.

    5. Laser Smoke (plume): Although brown spot/solar lentigo removal treatment normally involves minimal laser smoke, the smoke is noxious to those who come in contact with it. This smoke may be representing a possible biohazard.

    6. Skin tissue pathology: Energy directed at skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible. Only clearly benign pigmented lesions can be treated. Check with your doctor for a clearance for the treatment.

    7. Allergic reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations, have been reported. Systemic reactions (which are more serious) may result from prescription medicines. Allergic reactions may require additional treatment.

    8. Please wear sunscreen of SPF 25 or higher before and after treatment to protect your skin.

    9. I understand I may need multiple treatments for the desired outcome.

    10. I understand that exposure of my eyes to light could harm my vision. I will keep the eye protection on at all times.

    11. Compliance with the aftercare guidelines is crucial for healing, prevention of scaring, hyper-pigmentation and hypo-pigmentation.

    12. I release Rocky Mountain Skin Care Clinic from these liabilities.

    Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

  • Informed Consent for Photofacial/Skin Rejuvenation

  • I consent to and authorize Valerie Snaldome to perform treatments on me. Light can be used effectively to destroy targets located in the skin with minimum damage to the surrounding tissues. Light is used to lighten, fade or remove photo-damaged skin in a nonablative manner, a procedure known as photo rejuvenation. Visible sings of photo damage include wrinkling, enlarged pores, course skin texture, and pigment alterations.

    Photo-therapy, despite its high levels of efficacy and safety, is not free of side effects. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to seven days or longer. Irritation, itching, and/or a mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.

    Pigmentary changes such as hyper pigmentation and hypo pigmentation of the skin in the treated areas can occasionally occur. Mostly it is transient, lasting up to six months, but in rare cases it can be permanent. Most cases of hypo- or hyper-pigmentation occur in people with darker skin or when the treated area has been exposed to sunlight before or after treatment. Occasionally these pigmentary changes occur despite appropriate protection from the sun.

    Scarring, which can be hypertrophic or even keloid, can occur. Other known complications of this procedure include blisters, reddening, pinpoint pitted scars, bruising, superficial crusting, burns, pain, and infections. These side effects are usually temporary, lasting from five to ten days but can be permanent as well.

    The skin at or near the treatment site may become fragile. If this happens, makeup should be avoided and the area should not be rubbed, as this might tear the skin. A blue-purple bruise may appear on the treated area, which might last from five to fifteen days. As the bruise fades, there may be rust-brown discoloration of this skin, which fades in one to three months or longer.

    Additionally, there is a known and expected loss of hair in the treated areas. In a very small percent of people there is new hair growth in the surrounding areas being treated.

    Even though appropriate measures are taken to reduce side effects, they cannot be completely eliminated in every case. I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume these risks. There may be other treatment options, such as injections, other types of lasers/light sources or peels. With this in mind, I am choosing this non-invasive treatment for vascular and/or pigment lesions and other indicated skin conditions.

    Eye damage can occur from the light and therefore protective eyewear must be worn during all phototherapy sessions.

    I have read and understand the Pre and Post-Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of scarring, and other side effects and complications such as hyper pigmentation, hypo pigmentation, and other skin textural changes.

    I understand that this examination is not meant to replace the necessity for a complete dermatological examination.

    Photographs: I give permission for my photographs to be used to help document my treatment course. Complete confidentiality will be maintained.

    No guarantee, warranty, or assurance as been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results. Most patients require a number of treatments over several months with gradual results occurring over this time. Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received.

    I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.

    The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.

    I release Valerie Snaldome, medical staff, and specific technicians from liability associated with this procedure. I certify that I am a competent adult of at least 18 years of age. This Consent Form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

    Note: All prices are subject to change without prior notice.

  • Ultherapy Patient Consent

  • The Ulthera system delivers a low amount of focused ultrasound energy to the skin. The heat from the ultrasound stimulates new collagen to form. I understand that there may be some discomfort during the treatment when the ultrasound is being delivered.

    As with all medical procedures, there are possible post procedure effects and risks associated with treatment. Immediately following the treatment, the ski may appear red or slightly swollen in select areas, which may last anywhere from two to twelve hours.

    There may also be slight tenderness and tingling in the treated and surrounding areas for a few hours post treatment.

    Unlikely but potential temporary effects include, but are not limited to bruising, pigmentation changes or reduced sensitivity to touch. These would be mild in nature and would resolve in a matter of a few days or slightly longer. There is also a remote risk of scarring or motor nerve injury.

    It has been explained to me that the results vary from patient to patient, that in frequent cases results are not apparent, and that the procedure does not address every age-related issue on the surface of the skin.

  • Agreement

  • Please type your full name to veryify your agreement.
  • This field is for validation purposes and should be left unchanged.

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