First and Last Name
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Gender
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Date of Birth
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Phone number
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Address
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How Did You Hear About Us?
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What Treatment Are You Having?
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Laser Hair Removal
List The Areas You're Having Treated
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Face
Neck
Underarm
Arm
Hands
Chest
Back
Abdomen
Bikini
Legs
Feet
Have you had any of the below in the last 30 days?
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None
Sunbed
Self Tanning Cream
Tanning in the sun
Do you have any medical conditions listed below?
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None
Hirsutism
Polycystic ovarian syndrome
Port wine stain
Melanoma
Haemangioma
Anti inflammatory medication
Herpes (or cold soars)
Thyroid hormone deficincy
Diabetes
Hormonal imbalance
Heart disease
Burns / Graft skin
Cancer or radiation / chemotherapy
Keloid formations / scars
liver / Kidney disease
Epilepsy
Psoriasis
Shingles
Steroids of hormone therapy
Vitiligo
Aids
Lupas Diease
Pacemaker
Haemophilia
Clotting disorder
Anti coagulants
Pregnant
Given birth in the last 3 months?
Breast Feeding
Other - please list below
Are you currently using any photo sensitive medication?
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Yes
No
Are you currently using Retin A or Glycolic Acid?
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Yes
No
Are you currently using Roaccutane?
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Yes
No
Have you recently had a chemical peel?
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Yes
No
What products are you currently using on your skin, include body products?
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If you have an implant list the area of the implant
List any particular skin sensitivities or allergies you have
List any major surgery you have had in the last 3 months
INFORMED CONSENT. I hereby authorise Jodie Brown to treat me using the AW3® system.I understand that the reduction/ removal may not be 100%. I also understand that the treatment using the AW3® system may need to be performed in repeated sessions in the future to obtain optimal results. I have been informed about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have. I understand that there are certain risks associated with the treatment and they include but are not limited to the following:• Post-treatment discomfort like localised swelling, redness, bruising and mild tenderness. Other side effects are listed within the user manual. • Although uncommon the treatment may cause blisters or light burns to the surface of the skin. (Light /Laser Treatment Only). • Transient hypo or hyper pigmentation may occur and will normally fade in 3 to 6 months. • Crust formation “dirty skin” look is commonly seen for up to 10 days after treatment. (Light /Laser Treatment Only) • Scabbing, Swelling, and bleeding can occur but these are temporary. (Light /Laser Treatment Only)Below are a list of treatment(s) that will apply to me when accepting this consent. 1) Hair Removal: Intense Pulsed Light / Laser treatment is a method of treating unwanted hair. Unwanted hair may be caused by medical conditions such as hirsuitism, hypertrichosis and other disorders. Treatments using the AW3® System will not cure any medical conditions causing unwanted hair.The purpose of the treatment is to achieve cosmetic improvements by reducing hair growth by using Intense Pulsed Light /Laser to destroy hair follicles. 2) Thread veins /Pigmented lesions- Using the AW3® Intense Pulsed Light / Laser system is a method of treating vascular and pigmented lesions. The purpose of the treatment is to achieve cosmetic improvements using Intense Pulsed Light/ Laser to destroy vascular and/or pigmented lesions. 3) Skin Rejuvenation/ Acne Treatment- Intense Pulsed Light /Laser treatment is a method of treating sun-damaged skin. Over exposure to UV light can cause mottled/uneven pigmentation, open pores, sunspots and damaged blood vessels. Treatments using the AW3® system will not cure any medical conditions causing pigmentation or thread veins.The purpose of the treatment is to achieve improvements in the appearance of the skin by improving skin colour, tone and pore size using Intense Pulsed Light /Laser to target excess pigmentation and thread veins. 4) Wrinkle Reduction- Intense Pulsed Light / Laser treatment is a method of treating superficial fine lines and wrinkles. Everyday aggressors and skin ageing are some conditions that influence the skins collagen network and appearance. Treatments using the AW3® system will not cure any medical conditions causing fine lines and wrinkles.The purpose of the treatment is to achieve improvements in the appearance of the skin by improving collagen production within the dermis so therefore aiding in the skin turgor, texture and pore size using Intense Pulsed Light/ Laser.Patient's Face. Accepting Terms and Consent* I agree to follow the post treatment recommendations advised by operator/company above in order to ensure the best possible results. For Light/ Laser Treatments, I understand that excessive heat should be avoided for 48 hours and that exposure to the sun, including sun beds, must be avoided for 30 days before treatment and 30 days after treatment. (AW3 Super IPL and AW3 Super Laser may vary and your specialist can advise) A sun block of SPF 30+ must be used on the exposed skin areas, otherwise it might be possible that blotchy skin pigmentation, hyper- or hypo-pigmentation might occur.I agree to co-operate with the recommendations of the company or the personnel while I am under their care, realising that any lack of co-operation could result in less than optimum results.I agree to inform the above operator/company immediately if any adverse effects occur.I agree to photographic documentation of the treated area before and after the treatment. Images maybe shared within our community, members, social media, websites and affiliates unless you consent us not to. Any nudity and identity will not be shared. I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure.I agree to pay for the above mentioned services and understand that there will be no refunds for any performed services. This consent form and cost covers above selected treatments only. Additional treatments can be added to this consent form and will be charged for as per clinic price list, including single shot treatments.I have been made aware of the risks and I accept these terms and conditions as part of my treatment. We accept no liability for any of the above side effects. By accepting this, I agree to the terms and conditions and in the event of any of the above. I or any of my representative will not pursue the above person / company in any means of compensation.
I consent
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Yes
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Have you read and understood the cancellation policy? Can be found on our website and Instagram
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