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Another Clinic
Another Place
Another
Dr………………
Clinic…………..
Manufacturer…….. Date……………..
Dear Sir/Madam/Dr/Mr………
Reference :………………Client/Patient……………………
The above client/patient has attended my clinic in the hope of receiving electrolysis treatment for unwanted hair. During the consultation it was noted that Mrs …………….. advised that she has a pacemaker fitted. She is not sure exactly what device she has which means we cannot be certain whether she will be contra-indicated for treatment.
Please can you confirm whether she has an:
• Implantable Loop Recorder – ILR
• Pacemaker – Percentage of paced dependency
• Defibrillator
Mrs Blog has agreed for this information to be given and has signed below.
Name Printed………………………………………………………………
Signature…………………………………………………………………….
We await your reply before proceeding.
Yours faithfully,
Electrolysist name …………………………………………………………..BIAE member
Clinic………………………………………..
