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Appendix D: Customer Screening Checklist
🗆 Is 18+ years of age.
🗆 Does not have current or history of skin cancer or pre-malignant moles.
🗆 Is not pregnant or nursing.
🗆 Does not have any active skin conditions within the applied area, such as sores, eczema, rash, fragile,
swollen, burnt or injured skin, rosacea, dermatitis, or psoriasis.
🗆 Does not have rash as well as excessively/freshly tanned skin within the last few days.
🗆 Does not have vascular disorders such as: telangiectasia, varicose veins, thrombosis, phlebitis in the applied area.
🗆 Does not have severe concurrent disease such as: uncontrolled diabetes, neurological disorders, epilepsy, lupus, cardiac disorder, and cancer. In such cases, consult a physician.
🗆 Has not received any aesthetic procedure within the past 6 months such as: mesotherapy, peeling, resurfacing, fillers, gold/plastic threads, fat implants or products such as Accutane or Retin A.
🗆 Does not have known allergies to cosmetics/other products (including glycerin), or severe allergic reactions like hives.
🗆 Does not have impaired immune system due to immunosuppressive diseases such as AIDS and HIV or use of immunosuppressive medications.
🗆 Does not have skin disorders history such as keloid scarring, abnormal wound healing, and very dry and irritated skin.
🗆 Does not have any surgical, invasive, ablative procedure on treated area before complete healing. 🗆 Does not have any condition which may be unsafe for customer (per practitioner’s discretion).
SPECIFIC TO TRIPOLLAR RF TREATMENTS
🗆 Does not have pacemaker or internal defibrillator, implanted neurostimulators or any other internal electric system.
🗆 Does not have metal implants in the treated area.
🗆 Does not have history of bleeding coagulopathies or chronic use of anticoagulants.
🗆 Does not have history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treated area. These customers may be treated only following a prophylactic regime.
🗆 Does not have diminished or exaggerated perception of temperature changes.
🗆 Does not have Fitzpatrick skin type V (brown, dark brown) or VI (very dark brown, black). The safety and effectiveness of the device when used in individuals with darker skin (types V or VI) or may be prone to skin discoloration has not been established.
Appendix D continues on next page...
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