IPL Consent Form

IPL Consent Form

Native Beauty Medical Esthetics LLC
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First NameLast Name
What to expect during a laser treatment:

The sensation of light is sometimes uncomfortable and may feel like a moderate to severe pinprick or flash of heat.

The treated area may be red and swollen for 2-24 hours or longer. Cooling the treatment after may help reduce discomfort and swelling.

Common side effects include: temporary redness or mild sunburn like effect that may last a few hours to 3-4 days or longer.

Other potential side effects include, but are not limited to, blistering, crusting, irritation, itching, pain, burns, scabbing, swelling, broken capillaries, bronzing, and acne or herpe breakouts.

Pre Treatment Instructions:
- No Tanning (self tanner, tanning bed) 3-4 weeks prior to appointment.
- No lotions, body oils, perfumes, or makeup in the areas to be treated.
- No photo-light sensitive medications at least 10 days before treatment.
- Skin products to stop using: Retin-A for at least one week; Accutane for 6mo-1year
Pre Laser Hair Removal:
- No waxing or tweezing 3-4 weeks prior.
- Please SHAVE prior to treatment, the day before NOT THE DAY OF! (This can cause irritation and redness around hair follicles, razor burn, which can make it difficult for us to reach an end point)
- if desired, topical numbing may be applied at home within 1 hour of your appointment for pain tolerance. 5% lidocaine is available over the counter.
Hair Removal Only:
- Avoid fragrance lotions after your hair removal appointment for 24-48 hours until the follicles return to normal, they may appear red and inflamed the day of or after your session.
- 1% hydrocortisone can be applied for the first 24-48 hours.
- Avoid deodorant until skin & follicles returns to normal (24 hours is a safe call)
- 7-10 days after treatment the hair left under the skin will fall out.
- when the area is no longer sensitive, wash the area with a washcloth or loofah to help dead hair work its way out of the skin. This helps remove dead skin cells so the hair is able to shed out of the follicle easier.
- It may take 1-3 weeks for dead hairs to shed out of follicles. Return to shaving after irritation subsides.
  TREATMENT SCHEDULES:
- Lip, Chin, Underarm, Side Burns, Brazilian should be treated every 4-6 weeks.
- Leg Hair Removal should be treated every 8-10 weeks.
- it is normal to need 6 sessions MINIMUM, and upwards of 12 is OK. Everyone's hair type is different, and treatment schedules can continue based on your own disgression.
- 85% permanent reduction of hair is guaranteed.
- Annual treatment anywhere from 1-3 sessions is recommended.
Post Treatment Guidelines:
1. If needed, cooling the treatment area with cold packs is recommended to reduce swelling and ease discomfort. Do not use chemical cold packs.
2. No hot baths, aerobic exercise, rough sports, massage, etc. during the next 24-48 hours, until the skin returns to its normal condition.
3. Maintain high hygienic practices of the treated area during the next 5-7 days.
4. No tanning during the next 14 days (including tanning beds and creams). You should use high factor 30-50 SPF for at least 1 month post treatment.
5. Makeup can be applied immediately post treatment. In the case the treatment site scales or cakes, you should stop wearing makeup.
6. No heat, no sun, no sweating.
Please check any of the following that you may be affected by, that may inhibit you from receiving this service.
Use of Glycolic Acid (over the counter) Less than 10% -1 day; over 10% - 2 weeksUse of Retin-A, Differin Renova, Adapin - 2 weeksModerate peel - 1 month; Light peel - 2 weeksLiposuction - 2 monthsLaser - 2 monthsUse of oral isotretinoin (Accutane) within the last 6 monthsImplant surgery - 6 monthsDeep peel - 6 monthsLaser skin resurfacing - 6 monthsExposure to sun or artificial tanning during the past 3-4 weeks prior to treatment.Use of photosensitive medication or herbs within 2 weeks prior to treatmentBurns 6-12 monthsSurgical scars - 1 yearSkin graft - 1 year
Cancer, in particular skin cancer.Pregnancy, expectation of pregnancy, postpartum or nursing.Active infection or herpes simplex in the treatment area.Fragile and dry skinHormonal disorders, unless under controlUse of anticoagulantsUndiagnosed lesionsDiseases which may be stimulated by lightHistory of Keloid scarringDiabetes, unless under controlVitiligo (Hypo-pigmentation)Epilepsy
Inflammation at the treatment areaTattoosHistory or current permanent makeupMoles
By my signature below I certify that I have read, or have had read to me, and fully understand the contents of this consent for intense pulsed light therapy and that the disclosures referred to herein were made to me. I understand the risks and alternatives involved in this procedure. I also understand that there may be other treatment options. With this in mind I am choosing to try IPL, a non-invasive treatment for vascular and/or pigmented lesions, acne or hair removal. I have had the opportunity to ask any questions that I had, and all of my questions have been fully answered to my satisfaction. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Clinical results will vary per patient. No refund will be given.

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IPL Consent Form

Please check any of the following that you may be affected by, that may inhibit you from receiving this service.