Contact Elnes Clinic | Toronto, ON

ELNES Clinic

Confidential client record

VENUS BLISS MAX
Health Questionnaire & Informed Consent

Client information

Full name:

Date of birth:

Phone:

Email:

Date completed:

Height:

Weight:

Treatment goals / areas of concern:

Answer all general questions. Questions marked for a specific treatment apply only if you will receive it; otherwise select "Not receiving this treatment". Choose one answer per question. Yes / Unsure answers require assessment before treatment; not all are absolute contraindications. Confirm the planned treatments with your provider.

Medications and allergies

List all medicines / supplements (including anticoagulants, antiplatelets, thrombolytics, anti-inflammatories and aspirin; give aspirin daily dose):

Allergies and reactions:

Health questionnaire — everyone completes the general questions

Are you pregnant, possibly pregnant, breastfeeding or undergoing IVF? Specify which applies.
YesNoUnsure

Details:

Do you have a pacemaker, defibrillator or any implanted electronic device? Give the device type and location.
YesNoUnsure

Device type / location:

Do you have any metal or silicone implants, silicone injections, surgical mesh, plates, screws or an IUD? Give the type and location.
YesNoUnsure

Type / location:

Do you have current or previous cancer, a precancerous condition or a suspicious skin lesion? Give the diagnosis and location.
YesNoUnsure

Diagnosis / location:

Do you have any heart condition or other significant medical condition? Describe.
YesNoUnsure

Details:

Do you have diabetes, a nerve disorder, numbness, tingling or reduced sensation in the treatment area?
YesNoUnsure

Details of Yes / Unsure answers:

Do you have epilepsy, seizures or a degenerative neurological condition?
YesNoUnsure

Do you have a bleeding or clotting disorder, thrombosis, varicose veins or phlebitis? Give the location.
YesNoUnsure

Location / details:

Do you have wounds, infection, inflammation, irritated skin or an unhealed scar in the planned treatment area?
YesNoUnsure

Have you had recent surgery, trauma, a fracture or another procedure in the planned treatment area? Give dates and healing status.
YesNoUnsure

Dates / healing status:

Do you have any allergies or sensitivity to skin products, gels, adhesives or electrodes?
YesNoUnsure

Has a healthcare professional advised against treatment, or is there any other condition you have not disclosed?
YesNoUnsure

Details:

Do you have an immune deficiency (including HIV/AIDS), take immunosuppressive medicines or have a history of injected gold therapy? Specify.
YesNoUnsure

Details:

Details of Yes / Unsure answers:

Diode laser only

For each treatment-specific question, answer Yes / No / Unsure if you will receive that treatment. Otherwise select "Not receiving this treatment".

Diode laser only — Do you have an unrepaired abdominal hernia or an unrepaired disc problem / hernia in the treatment area?
YesNoUnsureNot receiving this treatment

Diode laser only — Do you have tattoos in the proposed area, an active tan, or recent tanning-bed / excessive sun exposure? Give dates and location.
YesNoUnsureNot receiving this treatment

Dates / location:

Diode laser only — Do you have photosensitivity, take photosensitizing medicines, or have a history of keloids or treatment-area scarring / fibrosis?
YesNoUnsureNot receiving this treatment

Diode laser only — Do you have a history or evidence of squamous cell carcinoma or melanoma?
YesNoUnsureNot receiving this treatment

Details of Yes / Unsure answers:

For each treatment-specific question, answer Yes / No / Unsure if you will receive that treatment. Otherwise select "Not receiving this treatment". General health answers apply to every selected treatment.

Treatments planned — select all that apply
Diode laser — localized fat reduction(MP)² — RF, PEMF and vacuum massageFlexMAX EMS — muscle conditioning

Treatment area(s):

(MP)² / RF only — Do you have a condition aggravated by heat, such as recurrent herpes in the treatment area?
YesNoUnsureNot receiving this treatment

(MP)² / RF only — Do you have an uncontrolled thyroid disorder?
YesNoUnsureNot receiving this treatment

(MP)² / RF only — Do you have a skin-related autoimmune disease?
YesNoUnsureNot receiving this treatment

FlexMAX EMS only — If abdominal treatment is planned, are you currently menstruating?
YesNoUnsureNot receiving this treatment

FlexMAX EMS only — If abdominal treatment is planned, do you have a chronic abdominal or intestinal condition, such as colitis or Crohn's disease?
YesNoUnsureNot receiving this treatment

FlexMAX EMS only — Have electrical stimulation, electrodes or conductive gels caused skin irritation or hypersensitivity?
YesNoUnsureNot receiving this treatment

Details of Yes / Unsure answers:

Informed consent — initial each applicable section

Initial each applicable section. Write N/A beside treatments you will not receive. Your provider must explain the selected treatments, material risks, alternatives and aftercare before you sign.

Selected treatments and health disclosure

I consent only to the treatments selected on this form and explained to me by a qualified, licensed professional. I have disclosed my conditions, implants, medicines, allergies and procedures and will report changes before each session. Yes / Unsure answers require assessment for each selected treatment. Screening must follow manufacturer requirements, including physician assessment where required. Signing does not establish suitability or override contraindications. I will not stop prescribed medication without instructions from the prescribing professional.

Client initials:

Diode laser — initial only if receiving this treatment

The 1064 nm diode laser heats targeted fat for localized fat reduction, not weight loss or treatment of obesity. The published indication is for BMI 30 or less. I may feel cooling and warmth. Risks include redness, tenderness, swelling, bruising and firmness; excessive heat can cause burns, blisters or skin injury, with possible pigment changes or scarring. My provider will explain the device-specific risks, recovery and aftercare.

Client initials:

(MP)² / RF — initial only if receiving this treatment

This combines radiofrequency, pulsed electromagnetic fields and vacuum massage. I may feel warmth and suction. Risks include redness, warmth, tenderness, bruising, irritation and burns or skin injury from excessive heating. Cellulite improvement may be temporary and maintenance may be needed. My provider will explain the intended benefits and limitations.

Client initials:

FlexMAX EMS — initial only if receiving this treatment

Electrical stimulation conditions healthy muscles; it is not intended to treat medical disease. I may feel tingling and muscle contractions. Risks include soreness, cramping, discomfort, skin irritation or hypersensitivity to stimulation, electrodes or conductive products. My provider will explain placement, limitations and risks relevant to me.

Client initials:

Preparation, aftercare and stopping

I will arrive with clean skin without lotions or creams on the treatment area, use required protective equipment and follow written aftercare. For laser, I will disclose tanning and avoid tanning beds and excessive sun for one week before and after treatment; laser must not be applied over tattoos. I will immediately report burning, sharp pain or unusual symptoms and may stop at any time. Severe/increasing pain, blisters, skin breakdown or signs of infection require prompt assessment. Other unexpected effects may occur.

Client initials:

Results, alternatives and questions

Results vary, are not guaranteed and may include little or no improvement. Multiple sessions or maintenance may be needed without guaranteeing benefit. These treatments do not replace a healthy lifestyle or medical care. My provider has explained reasonable alternatives, including no treatment, and answered my questions about the treatment, material risks and aftercare.

Client initials:

Records and voluntary consent

My information will be retained in my confidential client record under the clinic privacy notice. Marketing, photo publication or research require separate consent. I have read and understood this form and voluntarily consent to the selected treatments at ELNES Clinic. I may decline or withdraw consent for future treatment. My initials and signature do not waive my legal rights.

Client initials:

Client signature

By typing your full name below, you confirm that you have read, understood, and agree to this consent form, and you agree to use your typed name as your electronic signature.

Full Name (Electronic Signature) *

Or draw your signature below *