Laser /IPL Consent form Pre Patch test

Full Name* This field is required.

First Name

Last Name

Date of Birth

Date

Treatment requested* This field is required.

Hair Removal

Thread Vein / Vascular removal

Pigmentation

Tattoo Removal

Lifestyle & Medical History – please tick þor ý any that apply to you. If you do not understand or recognise the condition then please discuss this with your laser/IPL operator* This field is required.

Pregnant or planning pregnancy

Suntanned/Using sunbeds or fake tan

History of cancer or chemo/radiotherapy

Diabetes

Lupus

History of keloid formation/scarring

Photosensitive conditions

Epilepsy

Communicable Diseases (Hepatitis/HIV)

Lymphatic/Immune System Disorders

PCOS/Hormonal Imbalance

Thyroid Condition

Psoriasis/Eczema

Steroid Therapy

Herpes (shingles/cold sores)

High Blood Pressure

Depression/Anxiety

None of the above

Please can you comment about above and any other medical problems including any major medical treatment within the last 6 months?

Have you changed your medication or supplements since your original consultation?

Are you currently using/used in the last 3 months any of the following?* This field is required.

St Johns Wort

Gold Medications

Antibiotics

Anticoagulants

Roaccutane

Retin A

Amioderone

Steroids

None of these

Has the area for treatment ever had any of the following? * This field is required.

Moles

Birthmarks

Tattoos

Permanent Make-up

None of these

Has the area for treatment had any of the following procedures? * This field is required.

Chemical Peel

Botox

Injectable Fillers

Previous laser or IPL Treatment

Silhouette Soft Threads in the last 10 weeks

None of these

Has the area had a sun/sunbed exposure causing a tan in last 4-8 weeks?* This field is required.

Yes

If so has your tan fully faded?

Yes

What are your goals/expectations for the treatment?* This field is required.

Is there any possibility of pregnancy or are you breast feeding?* This field is required.

Yes

Please confirm the following was explained to you during your consultation: If you cannot remember please do not tick and we can go over this again before your patch test.* This field is required.

How treatment works

Typical no. Of treatments/interval

Possible side effects

Pre/post treatment care

Likely clinical outcome

Sensation during treatment

SPF Advice

Cost per treatment

Please read this consent form before your patch test /treatment we ask you to tick each box to indicate you understand & accept the information contained herein:* This field is required.

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 Technician before treatment if there has been any change (for example in medications).

I understand that the results from this treatment vary considerably and a small percentage of people will not respond satisfactorily to treatment.

I understand that multiple treatments are necessary to achieve satisfactory results.

I understand there is no guarantee of permanent results and maintenance treatments may be necessary. (Except tattoo)

I understand that for all treatment areas, there may be short-term side effects such as reddening, bruising, swelling, mild burning or blistering, hypo-pigmentation (lightening), or hyper-pigmentation (darkening), as well as rarer side effects such as scarring and permanent discolouration.

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.

Thread vein treatments on the face may cause swelling, reddening, bruising, and/or blisters under the skin particularly in the 24 hours after treatment. In some cases the swelling can be severe and may last a few days or even up to a week. You may want to consider staging your appointments at times when you can take time off from work, or at weekends.

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 I must wear protective eye goggles/glasses (supplied) to prevent damage from the light.

I understand that if I am receiving any free treatments as a result of purchasing a special offer, any unused free treatments are not refundable nor transferable to any other person.

I understand that when treating areas where there is hair growth, the hair follicle can be damaged preventing future hair growth.

I certify that I have read and understood all the information and my questions have been answered satisfactorily before signing this consent form. I acknowledge receipt of the After-Care leaflet. I consent to the terms of this agreement.

Please sign

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EmailPlease enter your email address so we can send you a copy of your consent form.

example@example.com