Vascular and Pigment

Vascular and Pigment

Consultation Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone

Medical information
Do you have any existing or recent illnesses?
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
Have you had warts?

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 {name} hereby authorize the therapist to remove or lighten the appearance of vascular and/or pigmented lesions. The procedure involves using a laser or pulsed light device to coagulate the vessels or vascular lesions and/or treat pigmented lesions, age spots, and sun spots by melanin absorption. I understand it may take multiple treatments to obtain optimal results. Although these devices are effective in most cases, no guarantees can be made. I understand I may not experience complete clearance, and that it may take multiple treatments. Some conditions may not respond at all and, in rare cases, may become worse.

The procedure may result in the following adverse experiences or risks:
- DISCOMFORT – Some discomfort may be experienced during treatment.
- REDNESS/SWELLING/BRUISING –Short term redness (erythema) is common and swelling (edema) of the treated area may occur. Additionally, there may be some bruising.
- SKIN COLOR CHANGES – During the healing process, there is a slight 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.
- WOUNDS – Treatment can result in burning, blistering or bleeding of the treated areas. If any of these occur, please call our office.
- BURNS and INFECTION - Infection is a rare possibility whenever the skin surface is disrupted, though 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’s surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.
- 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 sclerotherapy 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 informed should I become pregnant during the course of treatment.
Photographic documentation will be taken. I hereby:*

Accept authorisation of my photographs for teaching purposesDeny authorisation of my photographs for teaching purposes
ACKNOWLEDGEMENT

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR TREATMENT OF VASCULAR/PIGMENTED LESIONS AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.
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Vascular and Pigment

Medical information

Consent