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Microsoft word - bay view laser hair removal.doc

Bay View Laser Hair Removal
Full Name:___________________________________
Local Address: _________________________________________________________
City: _____________________________ State : ____________ Zip: ____________
Home# __________________ Work# ________________ Cell# ________________
SSN#: _______________________ Drivers License# / State: ______________________
Emergency Contact: ____________________________ Phone#: ___________________
How did you hear bout us? _________________________________________________
Please check any conditions that apply:
_____
Diabetic
_____ Mitral Valve Prolapse _____ Herpes _____ High Blood Pressure Other: ____________________________________ What method(s) are you currently using to eliminate your unwanted hair growth? ________________________________________________________________________ Authorization to Treat, Release Information
I hearby grant permission to Dr. Thomas McNeill, Jr. / Kristine Cox to examine, administer treatment and perform such general procedures, as he/she may deem necessary in the diagnosis and/or treatment of my condition. I authorize the release of any medical information necessary and permit a copy of this authorization to be used in place of the original Signature: _________________________________________ Date: ________________ BayView OB/GYN, P.A. | BayView Laser Hair Removal
I am aware that alexandrite laser treatment for hair removal is very new. I understand the nature, goals, limitations and possible complications of this procedure and have considered alternative forms of treatment such as electrolysis. I have had the opportunity to ask questions about the procedure, its limitations and possible complications (see below). The alexandrite laser poses an acceptably low risk of complication. As of April 1999, treatment with the Candela Alexandrite Laser has caused no significant complications to occur. However, since this is new technology, side effects most certainly will be discovered and may occur as more and more patients are treated. Tests and studies are ongoing regarding laser-induced hair removal. Although complications seem to be infrequent following alexandrite laser-induced hair removal, I understand the following side effects or complications may occur or are theoretically possible with an alexandrite laser and could happen to me. 1. Discomfort at the treatment site with transient redness and possibly some edema (swelling). 2. Decrease or increase in pigmentation typically lasting 1-3 months 3. Loss of pigmented lesions such as freckles, which may give the appearance of a loss of pigment 4. Activation of cold sores (we try to minimize this by giving you medication before your treatment which has been very effective with other laser treatments). CONSENT FOR LASER THERAPY FOR LASER HAIR REMOVAL

Print Name: __________________________________ Date: _____________________
Signature: ____________________________________
BayView Laser Hair Removal Questionnaire
Patient Name: ___________________________________________ 1. What area(s) are you interested in having treated? Check all areas that apply. 2. Do you have fair skin and dark hair in the area that you want treated? 3. Are you currently tanned in the area that you wish to have treated? 4. Are you currently taking any antibiotics? 5. Have you been using Accutane in the past 6 months? 6. If you are choosing treatment on the face, have you ever has fever blisters or cold sores? 9. Have you had a skin peel in the past 4 weeks? 10. Do you have a tattoo or permanent cosmetics in the area you want treated? 11. Please rate your skin type based upon the following scale and personal experience. _____ Type I - Always burn, never tan _____ Type II - Usually burn, tan less than average (with difficulty) _____ Type III – Sometimes mild burn, tan about average _____ Type IV - Rarely burn, tan more than average 12. Please list ALL medications that you are currently taking: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________ DRUGS THAT MAY CAUSE PHOTO-SENSITIVITY
ACNE MEDICATIONS
ANTI-PSYCHOTIC DRUGS
Chlorpromazine (Thorazine; & Others) ANTI-CANCER DRUGS
Prochlorperazine (Compazine; & others) ANTI-DEPRESSANTS

Amitriptyline (Elavil; & others)
DIURETICS
Bendroflumethiazide (Naturetin; & others) Hydroflumethiazide (Diucardin; & others) ANTI –HISTAMINES
Diphenhydramine (Benadryl; & others)
ANTI-INFLAMMATORY
HYPOGLYCEMICS

Naprosen
ANTI-MICROBIALS
Demaclocycline (Declomycin; & others) Griseofulvin (fulvicin-U/F; & others) HERBAL/ORGANICS
Methacycline (rondomycin) Nalidixix acid (NegGram; & others) Oxytetracyclines (Terramycin; & others) Sulfacyntine (Remoquid) Sulfamethazine (Neotrizine; & others) HORMONAL
Sulfamethizole (Thiosulfil; & others) Sulfamethoxazole-trimethoprim (Bactrim;Septra) Sulfasalazine (Azulfidine; & others) Sulfathiazole hyperpigmentation, dermatitis, or make the patient more sensitive to the laser treatment. BayView Laser Hair Removal
The alexandrite laser poses an acceptably low risk of complications. As of April 1999, treatment with the Candela Alexandrite Laser has caused no significant complications to occur. However, since this is new technology, side effects most certainly will be discovered and may occur as more and more patients are treated. Tests and studies are ongoing regarding laser-induced hair removal. Although complications seem to be infrequent following alexandrite laser-induced hair removal, I understand the following side effects or complications may occur or are theoretically possible with an alexandrite laser and could happen to me. 1. Discomfort at the treatment site with transient redness and possibly some edema (swelling). 2. Decrease or increase in pigmentation typically lasting 1-3 months. 3. Loss of pigmentation lesions such as freckles, which may give the appearance of a loss of 4. Activation of cold sores (we try to minimize this by giving you medication before your treatment which has been very effective with other laser treatments). 5. Folliculitis (inflammation of the hair follicle). 6. Scars or loss of pigment will probably occur at some low frequency, although the incidence is not available yet because these problems have not yet been encountered. This can be attributed to the fact that large numbers of patients have not had this treatment yet. 7. Small blisters and/or crusting. 8. Redness after treatment for about two days. This list is not inclusive and additional side effects may occur, but I elect to proceed forward with treatment. I have been given a patient information brochure and have read it, understand it and have asked any questions I had regarding the procedure. Patient: ________________________________________________ Date: __________________ BayView OB/GYN, P.A. | BayView Laser Hair Removal
ALEXANDRITE / LONG PULSED YAG LASERS
HOW THE LASER REMOVES HAIR
The Alexandrite / Long pulsed yag lasers are used to remove hair by destroying the hair follicles. Once a hair follicle is destroyed, hair will not regrow from that particular hair follicle. Different lasers utilize different wavelengths of light energy. The alexandrite/long pulsed yag lasers are absorbed by the hair follicle. When the laser energy is absorbed, the laser energy is transferred to the follicle. If sufficient energy is absorbed, it kills the hair follicle. At any particular time, approximately 30% of hair follicles are in an actively growing state, while the remainders are in resting state. Only hair follicles that are actively growing hair will be susceptible to damage from the laser light. Those hair follicles that are in a resting state will not be damaged. This means that each laser treatment will destroy about 30% of the hair follicles treated. Multiple treatments are required to clear an area of visible hair. Significant hair reduction usually requires a minimum of three treatments sequenced at 4-6 week intervals and can require four or more treatments depending upon hair type and density. A yearly touch up treatment could possibly be required. In addition, certain types of hair are better at absorbing laser energy and thus, are more susceptible to laser hair destruction. In general, the darker and heaver the hair, the greater the absorption of laser energy. The lighter and finer the lair, the less laser energy is absorbed. Therefore, the laser hair removal is more effective on darker heavier hair. Generally laser energy will not affect blonde or grey

Source: http://www.bayviewlaserhairremoval.com/PatientForms.pdf

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OVULATORY DISTURBANCES: THEY DO MATTER from: The Canadian Journal of DIAGNOSIS February 1997 For the woman who isn't trying to get pregnant, does it matter if an ovulatory pattern is normal? Recent studies indicate that it does. One study showed that women with only one nonovulatory cycle a year lost an average of 4% of their spinal bone. Strong evidence suggests that lack of cyclic normal

Microsoft word - pace bulletin vol 6 no 4 pacef january 2012.doc

Volume 6; Number 4 February 2012 What’s new this month? Both tapentadol immediate release tablets (Palexia) and tapentadol prolonged release tablets (Palexia SR) have been designated RED-RED (see page 3). Atorvastatin chewable tablets (Lipitor) are designated RED-RED, although it is recognized that there are exceptional circumstances where they may have a limited role (i.e. hyperc

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