LASER/IPL CONSULTATION FORM

LASER / IPL CONSULTATION FORM

Surname:____________________________________ First Name:________________________________________________

Mr/Mrs/Miss/Other:__________________________ DOB:___/___/______

Home Address:_________________________________________________________________

Post-code:_______________________________

Mobile No:_____________________________

Email:_________________________________________________________________

Emergency Contact Name:_________________________PhoneNumber:__________________________________________

Ethnic origin:____________________________________ Occupation:_________________________________________

Treatment Requested (please circle)

Hair Removal Skin Rejuvenation Vascular Pigmentation Acne

Tattoo Removal Fractional Laser ILLUMIFacial

Other:____________________________________________Body Area(s):______________________________

Useful Comments_____________________________________________________________________________________________

Lifestyle & Medical History - PLEASE CIRCLE each condition as appropriate. If you do not understand or recognise the condition then please discuss with your laser/IPL operator

Pregnant (or planning pregnancy) PCOS/hormonal imbalance
Sun tanned/using sun beds or fake tan Thyroid condition
Skin pigmentation disorders (e.g. melasma, vitiligo) Regular smoker
History of cancer (or chemo/radio therapy) Psoriasis/eczema
Diabetes Depression/anxiety
Epilepsy Herpes (shingles/cold sores)
Lymphatic/immune system disorders High blood pressure
History of keloid formation/scarring Photosensitive conditions Lupus Communicable diseases (hepatitis/HIV) Units alcohol/week_______

Useful Comments_________________________________________________________________________________________

__________________________________________________________________________________________________________

ARE YOU:

Currently taking an medication or any supplements?

____________________________________________________________________________________________________________________________________________________________________________________________________

Currently using/used in the last 6 months, any of the following? (please circle):

St John's Wort Amiodarone / Minocycline Anticoagulants

Gold Medications / Oral or Topical Retinoids (e.g Roaccutane or Retin A) / Oral or Topical Steroids

Comments: ___________________________________________________________________________________

Recovering from any major medical treatment or photodynamic therapy (PDT) within the last 6months?

No/Yes (please specify)_______________________________________________________________________________

Does the area for treatment have: (please circle)

Moles / Birthmarks / Tattoos / Permanent makeup / Chemical peel / Botox / Injectable fillers / Tanning Injections or Enhancers

Skin disorder/disease? No/Yes_______________________________________________________________________________

Had previous Laser or IPL treatment? No/Yes

Your skin:

What products do you use on your skin? ______________________________________________________________

Please INDICATE how your skin responds to midday summer sun exposure with no sunscreen:

Skin Type 1 Always burns, never tans

Skin Type 2 Easily burnt, eventually gets a moderate tan

Skin Type 3 Sometimes burns, quickly gets an average tan

Skin Type 4 Rarely burns, quickly gets a deep tan

Skin Type 5 Very rarely burns, consistent tan

Skin Type 6 Never burns, consistent tan

Do you currently have a real or fake tan?Yes/ No

How long ago was your last UV exposure? ___________________________________________________________________

Have you ever used tanning injections/enhancers/MeIanotan ?Yes/No_______________________________________

What are your goals/expectations for the treatment?__________________________________________________________

Where did you hear about the clinic? Recommendation/Advert/SocialMedia/Press/Other_____________________________

Pre Treatment Check List

To be completed by the operator (TICK to confirm points have been discussed)

Cost per treatment
Sensation during treatment
Possible side effects
How treatment works
Pre/Post treatment care
Any further questions/ Comments
Soothe/LightProtect recommended
Likely clinical outcome
Typical no. of treatments/interval
Photograph taken

Any further questions / Comments:____________________________________________________________

_____________________________________________________________________

Informed Consent for IPL/Laser Treatment

Please read this consent form and initial each number to indicate you understand and accept the information contained herein.

The information I have given is correct to the best of my knowledge, and I have not withheld any known medical state or condition. I will inform the IPL/Laser operator before treatment if there has been any change (for example in medications taken).

I understand that the results from this treatment vary considerably and a small percentage of people will not respond satisfactorily to treatment.
I understand multiple treatments are necessary to achieve satisfactory results
I understand there is no guarantee of permanent results and maintenance treatments may be necessary.
I understand that I must avoid sun exposure on the treated area for the duration of the treatment (and for up to 1 month afterwards) or use a high sun protection factor to avoid sun damage. I understand that tanned skin cannot be treated.
I understand that there may be short-term side effects such as reddening, bruising, swelling, mild burning or blistering, hypo-pigmentation, (lightening of the skin) or hyper-pigmentation, (darkening of the skin), as well as rare side effects such as scarring and permanent discoloration.
I understand that pigmented areas caused by sun damage may initially turn darker. This will be followed by 'micro-crusting' of the lesion, after which it should flake away leaving an area without excess pigmentation.
I understand that I must wear protective eye goggles to prevent damage from the light.
I agree that my contact details can be used to be kept updated about special offers and other information about the clinic and its services that might be of interest.
I certify that I have read and understood all the information and my questions have been answered satisfactorily before signing this consent form. I consent to the terms of this agreement.

Client Name:________________________________________ Client signature:_________________________________

Operator Signature:_______________________________________ Date:__________________

Treatment Assessment (to be completed by the operator)

Hair Removal Assessment (please circle)

Hair color Black Dark Brown Light Brown Red Blonde Grey/White

Hair texture Coarse Medium

Hand-piece Selection 650 650 Advance Nd:YAG Alexandrite Diode

Previous/current treatments_____________________________________________________________________________