Laser Genesis Skin Therapy

LASER GENESIS SKIN THERAPY

Consultation Form
Client Name

First NameLast Name
Date of Birth

DayMonthYear
Date of Birth
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Home Phone Number
Phone number
Mobile Phone Number
Phone number
Medical History
Short Text
Do you have any existing or recent illness?
Recent illnesses
Have you had any hospitalizations or surgery?
hospitalizations / surgery
Please list any Medications
Medications
Do you have any Known Allergies?
Known Allergies
Have you had any Aesthetic procedures?
Aesthetic procedures
Have you tested positive for coronavirus?

YesNo
Are you (please select all that apply)?

Under 18?Any pacemakers, internal defibrillator, other implanted neurostimulators or any other internal electric devise?Metal implants in the treatment area?Pregnancy or nursing?Current history of cancer, especially skin cancer?Impaired immune system due to immunosuppressive disease such as AIDS & HIV?Severe concurrent conditions such as cardiac disorders, epilepsy or lupus?Poorly controlled endocrine disorders such as diabetes?History of bleeding coagulopathies, or use of anticoagulantsA history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area?Diminished or exaggerated perception of temperature change?Any active condition in the treatment are such as sores, hemorrhages, risk of hemorrhages, septic conditions, psoriasis, eczema and rash as well as excessively/ freshly tanned skin?History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin?Any surgical, invasive, ablative procedure in the treatment area before complete healing?Any medical condition that might impair skin healing?Are you taking any of the following medications or supplements?- Herbal preperations, food supplements or vitamins that might cause fragile skin or impaired skin healing such as prolonged steroid regime, Isotretinoin (Accutane), Tetracyclines, or St. John's Wort?Have you had any Aesthetic procedures in the treatment areas such as- Fillers? Date?
If you have had aesthetic procedures in the treatment areas, please provide details and date(s):
Aesthetic procedures in treatment area
Consent
I hereby authorize the therapist to perform Laser Genesis Non-Ablative Skin Therapy on me. I understand that this procedure works on promoting vibrant and healthy-looking skin by creating a thermal response in the dermis that stimulates new collagen. I understand that multiple treatments are required and it is possible the result will be minimal or not help at all.

I am aware of the following possible experiences/risks:
- DISCOMFORT – A slight warming sensation may be experienced during treatment.
- REDNESS/SWELLING/BRUISING – Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.
- SKIN COLOR CHANGES – During the healing process, there is a possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in colour compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.
- ITCHING/DRY SKIN – Treatment may result in itching and/or dry skin.
- RED RASH/BUMPS – Red rash/bumps may appear after treatment. This resolves with time.
- WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our office.
- INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our office on 01582 460868.
- SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.
- SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING - May increase the risk of side effects and adverse events.
- EYE EXPOSURE – Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.
I acknowledge the following points have been discussed with me:
- Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me
- Alternative treatments such as topicals, microdermabrasion, or surgery
- Reasonably anticipated health consequences if the procedure is not performed.
- Possible complications/risks involved with the proposed procedure and subsequent healing period
For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep The AL5 Aesthetics and staff informed should I become pregnant during the course of treatment.

Photographic documentation will be taken.
Authorisation for photography*

I do authorise photography to be takenI do not authorise photography to be taken
ACKNOWLEDGEMENT

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR LASER GENESIS TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.
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LASER GENESIS SKIN THERAPY

Medical History

Consent