IPL Consent & Waiver

La Ritz Spa & Salon IPL Treatment Informed Consent

Medical History
Name *

First Name Last Name
Birthdate *

Month Day Year
Date
Age
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
I Authrorize the Medical Technician To Perform Treatments on Me *

I Agree
I understand that sun exposure or tanning of any sort is not aligned with the pre and/or post care instructions and may increase the chance for complications *

Yes

IPL Treatment Informed Consent

Medical History Page 2
I understand that there is a rare possibility of side effects or serious complications including permanent discoloration and scarring. I am aware that careful adherence to all advised instructions will help reduce this possiblity. *

Yes
The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered *

Yes No
I Understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment and how many sessions will be required *

Yes
Pre and post care instructions have been discussed and are completely clear to me *

Yes No
I understand the below list of short-term effects and agree to follow matching guidlines *

Yes
Flaking of pigmentated lesions - crust may take 5 to 10 days to disappear and it is important not to manipulate or pick which may otherwise lead to scarring Discomfort - During the procedure, I might experience a sensation similar to a rubber band snap which degree will vary per my skin condition and area sensitivity but that does not last long. A mild "Sun-Burn" sensation may follow for typicalluy up to one hours and will be reduced with application of cooling and soothing creams. Reddening and swelling - severity and duration depend on the intensity of the treatment and the senisitiviy of the area to be treated. The phenomena may be reduced with application of cooling and/or anti-inflammatory creams Brusing may rarely occur and may last up to 2 weeks.
I agree to review the following IPL pre-treatment compliance checklist along with my medical Technician and bring accurate and updated data, to the best of my knowledge *

Yes
Natural or artificial sun exposure in the past 3-4 weeks pre-op or the following 3-4 week post-op plan Use of self–tanners or tan enhancer caps within the past 3-4 weeks pre-op plan Photosensitive herbal preparations (St John’s Wort, Ginkgo Biloba, etc) or aromatherapy (essential oils) Diseases which may be stimulated by light at 400 nm to 1200 nm, such as history of Systemic Lupus Erythematosus or Porphyria Pregnant or possibility of pregnancy, postpartum or nursing

IPL Treatment Informed Consent

Medical History Page 4
Intake of aspirin or anti-coagulants? *

Yes No
Easy Bruising *

Yes No
Any Known Allergies *

Yes No
If Yes, Please List Allergies
My signature certifies that I have duly read and understood the content of this informed consent form, and gave the accurate information as to my health condition. I hereby freely consent to M22 IPL skin treatments
Name of patient (please print) *
Signature of patient *

Clear
Date *

Month Day Year
Date
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La Ritz Spa & Salon IPL Treatment Informed Consent

IPL Treatment Informed Consent

IPL Treatment Informed Consent

IPL Treatment Informed Consent