(NTEGRATED DERMATOLOGY OF MISSION VIEJ( !6691 PLAZA STE 230 MISSION VIEJO. CA 92691 J4'RANK Q ZHAN MD AND FRANCES.J SEGAL MD

Phone (949) 364-2904 Fax (949) 364-2909

Medical History for Laser Based Treatments last Name: First Name: _

Address: . _

City: State: Zip Code: _

Telephone: Home: Work: Cell: _

Date of Birth: .. Sex: Female Male

Family Doctor: Phone: _

Pharmacy: Phone: _

.Emergency Contact: Phone: _

Which body area/areas or condition would you like treated?

Please answer all of the following questions 1. Do you have ANY current or chronic medical illnesses?

Disclose any history of heat urticaria, diabetes, autoimmune disorders or any immunosuppression, blood disorders, cancer, bacterial or viral infections, medical conditions that significantly compromise the healing response, skin photosensitivity disorders, or ~ other condition or illness.

Please list: _

YES NO o 0

2. Do you have ANY current or chronic skin conditions? Also disclose any history of vitiligo, eczema, melasma, psoriasis, allergic dermatitis, any diseases affecting collagen including Ehlers-Danlos syndrome. scleroderma, skin cancer, or ~ other skin condition.

Please list: _

o 0

3. Are you currently under a doctor's care? If so, for what reason? o 0

4. Do you take/use ANY medications (prescriptions and non prescriptions), vitamins, herbal or natural supplements, on a reqular or daily basis?

Please list: _ o 0

5. Are there any topical products (both medical and non-medical) that you use on your skin on a regular or daily basis?

Please list: _

6. Do you take/use ANY systemic/oral steroids (e.g., prednisone, dexamethasone)? [J [J

INTEGRATED DERMATOLOGY OF MISSION VIEJ( Z6691 PLAZASTE 230 MISSION VIEJO, CA92691 FRANK Q ZHAN MD AND FRANCES.J SEGAL MD

Phone (949) 364-2904 Fax (949) 364-2909

YES NO 7. Do you have ANY allergies to medications, foods, latex or other substances? 0 0

Please List: 8. (For women) are you or could you be pregnant? 0 0 9. (For women) are menstrual periods regular, or have you 0 0

ever been diagnosed with pOlycystic Ovarian Disorder? 10. Do you have a history of herpes I or II in the area to be treated? 0 0 11. Do you have a history of keloid scarring or hypertrophic scar formation? 0 0 12. Do you have a history of light induced seizures? 0 0 13. Do you have any open sores or lesions? 0 0 14. Do you have any history of radiation therapy in the area to be treated? 0 0 15. In the last six (6) months, have you used any of the following: 0 0

anticoagulants or blood-thinning medications; photosensitizing medications; or anti-inflammatory or blood thinning medications? Please List product name and date last used:

16. In the last three (3) months, have you used any of the following products: glycolic acid or otheralphahydroxy or betahydroxyacid acid products; exfoliating or resurfacing products or treatments? 0 0 Please List product name and date last used:

17. Do you have or have you ever had any permanent make-up, tattoos, implants, or fillers,including, but not limited to, collagen, autologous fat. Restylane". etc.? 0 0 If yes, please list locations on or in the body and dates:

18. Do you have or have you ever had any Botulinums, such as Botox" or Dysport"? 0 0 If yes, please list locations on or in the body and dates:

19. Have you taken Accutane" (or products containing isotretinoin) in the last 12 months? 0 0 20. Have you taken Tretinoin (like Retin-A®, Renova®) in the last 6 months? 0 0 21. Have you had any unprotected sun exposure, used tanning creams (including

sunless tanning lotions) or tanning beds or lamps in the last 4-6 weeks? 0 0

SignaLUre: Oate: _

lNTEGRATED DERMATOLOGY OF MISSION VIEJ( Z6691 PLAZA STE 2JO MISSION VIEJO, CA92691 FRANK Q ZBAN MD AND FRANCES J SEGAL MD

Phone (949) 364-2904 Fax (949) 364-2909

8<in Typing Worksheet

Client Name: Date:

Score:

l.ighr Bluv or Dark Brownish What is your eye color? him.' or green brown black gray

Dark Red, Blonde blonde', Dad, Bi.1,k What is the natural color of your hair? S.1ndy red chestnut. brown

Brown

What is the color of your skin l),llc with .iglu Dar k Reddish Verv I',d~ betge uru brown brown (unexposed areas)?

Do you have freckles on sun-exposed \(,1Il), ~(,V\~ITd Few lnctdcnral r..om'

areas?

Parnful 13btcnn;!. Burn •. , Never What happens when you STay in the sun redness. rollowcd sometime -, Rarely had too long? blisrenna. bv 10 I lowed burns burns peelmg peehng b~ peclmg

Turn ll.!rdl~ Reasonable Tan very d..uk To what degree do you turn hrown? nnv or l.rght ran [3.n easilv brown

not',H ,Ill quickly

Do you turn brown several hours after :\f'vcr Seldom Someurncc Orren I\\W,l)'" sun exposure?

Very Never

How docs your [ace respond to the sun? Very Scnsrnve Normal had .1 senstttvc resistant problem More 2- '; 1.1::.:- rb.ru Less dun When did you last expose yourself to the thau } ruonrh- 1 .1 mcmh v 1 ruonrh 2. week ...

sun, tanning bed or self-tanning creams? months ago ago .igO ,1[;0

.1gO

:--';e,:('r l I.trdlv :)l)IIIl:iII11t:) Often Always

ever

------1-+ IT 1lI IV

V-Vl

17-25 26-30 Over 30

--------...

lNTEGHATED DERMATOLOGY OF MISSION VIE.J( Z6691 PLAZA STE 230 MISSION VIEJO, CA92691 FRANK Q ZHAN MD AND FRANCES.J SEGAL MD

1. I understand that this eieci.ve. treatment is being provided as part of a demonstration of the ::steL.iX"'! MediLux"il/StarLuX®/StarLuX® 500 /Artisan™/ Palomar Icon™/Palomar Vectus™ System to (1 potcntiot purchaser or licensed practitioner. I have requested and/or accepted that the Palomar Medical Iechnoioqies. ir:c:. S(];CS

representative provide treatment instead of and as the delega;e of ihe Licensed Practitioner. : unoorstor-o that Ihc Palomar soles represeniotive may not be a iicensed practitioner.

2. The purpose of this dernonstrotion is to provide a cosmetic derrnoroiocv rreorrnent. incitJdinq bui r ot i;mileci ;~) IJ8pr tiS5U() heating. soft ri~slle coaguioiion. skin mSllrTocing, "educiro or eiirnin(11:r.g i~o;,. pigrn(.,rJird 'c',i<),lS (sun spots. age spots, and other si:in disco.orof.ons). vascular 'esions [veins). Gene, acne scars or surqico: seers. wrinkles, and/or toitoos. There is no gua~an'(ee that the expected or cnticipoted results wiii b;, oc h.ovcd. understond lhot the results vary 'Niih each indiviciuoi one thct rnuliiple Ireotments rrov be rieccsscrv.

3. The EsleLu),k) MediLux'~/SjarLux®/StarLuX®500 /Artisan,M/ ?olor:lar Icon™/Paiomar Vec.;lus™ Svs.er-is oe-iver c precise puise of I;ght energy (either loser or lamp) :hai is obsorbed by 0 cnromophcre ;r. skin, '01 0XOr;-·.p:,:, 'h(; pigment in hair, causing a thermal reaction. Ail personnel irl ihe treatment 1'00[:1, includir.o me. wiH weo: protective 0Yt"}Wl;'Ur to prevent ey~ aur:',uge from [his ir'ite;'lsee light energy

4. Tile sensatinn oi light is sometimes uncornforto ole or.d may feel !ike a moderate :0 severe pi:lpr:ci< or f:Gsh ot nect. If lhe Licensed Praciitioner 01 physician elects to use a local anesthetic, all options will be oiscusseo W;Tn me.

5. Following Inc procedure 'he area may be red ond swoilen Ior 2-24 hours or longer. Co.o packs 1',eN ::dp reduce oiscorntort eric swelling.

6. I unoers+orio tnot: Cor-irnon Side eifec:s rr.clude temporary redness end m:!d "sunb •. .J!f( ;;ke E:J!0C!S rho: may os a few hours in 3-4 days or lor.qer. Pig:nent changes, including hvpooiqrnentotion pigll!ening Of :he SK:r,~ or hyperpigmentCljic>r~ (dOl kening oi HIE: skin), lasiing 1-6 months or longer or per.r-onent.y may OCCLl'. in addi;ion, freckles may temporarily or permanently disappear in ireoreo areas. Oiher potential risks inclcde. OJ: ore nor iimited TO, b:eedi'lg, crusting, imtction. itChing, poin. ir,grown heirs. cuts and nicks from s::oving, bn;i~;'~J, (),J:n.:. poor healing, infection. scabbing, scarring, swellir,g, broken copisories. bronzing, and Ioi.ure to ac;,;e,/E I! If;

desired resort. There also ore risks of resulting unsotistoctorv appearance.

I. Some serious but rore co-np:ications are possible, such as, acne ond herpetic breakouts, otooo ciois sxir: 'OSS,

serorno (pockets of serum fluid in oreos where iissce has beer1 removed), hematomas (col!ectio;-: of b'ooo under ire skin), abscess, skin necrosis (dead skin), necrotizing fasciitis (tissue damaged 0)' occre-.c). i('.jury TO other internal strucrores inciuding nerves, blood vessels, or muscles, allergic reaction ;0 medicorions or materials used during pwcedure.

8. With ooloflve laser treatments, there me odciitional -isks of discomfort. focal areas of bleeding. bruising, poor hFJn:ing. serous oischoroe ora infeciion~ Serious but rare comoiicctior.s moy inciucie 5CC1'(ino (10<;(':0.5> ;;k;r. necrosis (deaa skin), and ;njury io other interool structures including nerves, blood vesS~)iS, or mUSC;(0S.

9. Anesthesio or sedotion (coirr:ing medication) may be odviscble. I hereby cor-sent to trie adrnifl:sl~a!iorl c: any anesthesia and sedation or sedorlon considered necessary or advisable for my procedure(s). I < .. n,jerSkH'(j ;"0: ail forms of c-iesthesio involve risk and the possibility of complications, injury, and in rare instances ci~otr..

10. i ur.derslond ;1\Oi m)y post -operotive followop or scbseqt.enl medicol :recimer,:s should be direc::y wi'!' the Ucenseu Pruciifioner.

11. ;ndc:5 :,0 gl.'c:rOI',tee thct tr.e expecled or onnciooteo results will be ccrueveo.

12. i coosen! to photographs ana digiicl images being iail.en to evaiuate treoiment eff0c"veness, 'Of meoicci educcrion. iroinino. protessionoi publicotior.s or sales purooses. No photographs or dioito: innages revecino :-,)' idenii:y 'Nill be used wiihcur my written consent. If my idenriiv is not revealed, I authorize tho: hest? photoqrcphs and digital images may be used, shared, and disployed publicly without my perr-ussion.

lNTEGKATED DERMATOLOGY OF MISSION VIE.J( Z6691 PLAZA STE 230 MISSION VIE.JO, CA 92691 FRANK Q mAN MD AND FRANCES.J SEGAL MD

13. Sun, ianning bed, or tanning lamp exposure, the use of sell-tonninq creams, and not adhering to the post­ treatment instructions provided to me may increase my chance of complications. I must avoid the sun. tanning beds, and sunless tanning lotions and use sunblock (SPF 45 recommended) after treatment.

14. There is a possibility of coincidental hair removal when treating pigmented or vascular lesio s in hoir-beorlnc areas. There is a risk tho lhe hair regrowlh rnay be changed, such as little or no regrowth or more regrow h than before.

15. There is chance that hair treatment may cause Increased hair growth, increased numbers of hair toinctes. ano uneven or patchy hair growth, There is a high risk of increased hair growth in people of Middle Eastern and Mediterranean descent and those who have an ill-defined hair line with no obvious transition of fhe hairline to the face. These changes may be temporary or permanent.

16. I should call my provider as soon as possible if I have any concerns about side effects or complications after treatment.

17. Not providing my medical history before proceeding with a light-based treaiment could impact treotmen results and cause complications.

lB. I have read and understand all in ormation presented to me before consenting to Es!eLu;..,c,/MediLu)(1;/ StarLuX@/StarLuX@500 /Artison™ / olomar Icon™/Palomar Vecfus™ treatment. I have also been given the opportunity to ask questions and have had all my questions answered.

Before and after-treatment instructions have been discussed with me. The procedure, potential benefits and nsks, and alternative treatment options have been explained to my satisfaction.

I freely consent to the proposed treatment today.

Client ~igr:01:.ye: _ Dote:

Print name: _

Witness signature: Dote: _

Print name: _

Ccmsen.tfor Laser Treatment

lNTEGRATED DERMATOLOGY OF MISSION VIE.J( Z6691 PLAZA STE 230 MISSION VlE.JO~ CA 92691 FRANK Q mAN MD AND FRANCES.J SEGAL MD

Phone (949) 364-2904 Fax (949) 364-2909

Exdusionary Qiteria

Patients Name: . _Date

Exclusionary criteria for light therapy Includes, but IS not limited to:

. Blood disorders. Conditions or medications that alter ability of blood to coagulate should be excluded from vascular treatments .

. Unprotected sun exposure or use of tanning beds or creams in areas to be treated. Protected sun exposure means wearing protective c'othmq or the daily use of an SPF-30 or qreater sunscreen. Pauent should be advisee to discontinue tanning four weeks prior to treatment, during treatment course and 4.6 weeks after treatment. Thrs will reduce the chance of skin color changes and development of new pigmented lesions.

- Pregnancy. There is no clinical evidence at t Ius time of fetdl harm from a light-based system, but results of the treatment may be erratic or unreliable due to fluctuations In hormonal levels, hair growth cycles and pbvsroloqicat condrnons.

-Menstrual Dysfunction. Patients With menstrual dysfunction or hvperandroqerusrn s ould be referred to an endocrinologist for evaluation and possible medical treatment. These patients tend to have irsutism secondary to their disease, which may respond to rnedicat treatment.

- Use of mechanical epilation less than six weeks prior to treatment for patients seeking hair removal. This Includes plucking, waxing, twee zinq, electrolvs.s or sugaring. Patient should also refrarn from these practices dunnq the treatment course.

· Allergies. Confirm With a patient any allergies to medications, latex, foods, or other substances that may be used during the course of treatments.

- History of Seizures. Flashlllg lights may trigger d seizure.

· Medications. Both pr escnption and nonprescriptron. Be sure to rnclude herbal a d natural remedies as son re of these may cause photosens tivity. Pauent should not be taking Accutane, ann-coaqulants or St. John's Wort

· History of keloid and hypertrophic scar formation. Although scarnng is rare, picking or pulling off scabs 01

crusting can result in 5calTlI1g. For tlus reason it is recommended to exclude from treatment patients With known tenoency to form keloid or hvpertropluc scars.

· Active infections/Immunosuppression. Active infections and immunosuppression compromise the healing ability of the body. Reschedule the patient when mfectlo-i IS cleared.

· Open Lesions. Treatment should only be done Oil intact, healthy skin With the exception of acne-effected Skin

· Herpes I or II within the trea rnent area. Patients should consult therrpnrnarv r a.e providers for medn.al evaluation and possible prophlaxrs.

-Tretinoin (Retin-A, Renova). Altnouqh tretmorn use III the "rea to be treated i nor absolutely contramdicated, It 5 known to make skin 11101 e sensuive and prone tl' exfoliation Parrent IS better advrsed to discontinue the use of exfoliating (l"edllb and otbe e,<fol,atlllY products two weeks PrlOI til ano cI I' ng the entire treatment course

· Oral isotretinoin (Accutane) within the preceding 6 months. i\ccutane changes tne unde-ly ng structure of tue Skill, '.'II1,ch Illay cause unrel able results. It mav JI~o Increase Skill sensiuvuv tn hqh

· Diabetic patients must neve 1I1("o«al clealdnLP by til,"I' Pilllldl'l car e Phy'>ILldll nor to any treatruents

- Pigmented lesions must be identified H b I lign by a ualified physician prior to treatment. Inaccurate diagnosis and inadv ert nt treatment of a ski" Gil' rill' y lead to a delay ill receiving proper medical care.

P"tll'llt:, qnatur ~ Date

Date