IPL PhotoFacial Consent Form

Illume Skin Spa

IPL PhotoFacial consent form
Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

AreaPhone Number
How did you hear about us?*
If referred, by who?
Your Medical History
Are you currently under the care of a physician?*

YESNO
Have you experiences any of these health conditions in the past or present?*

Cancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemAuto-immune DisorderCold soresHIV/AIDSNoneOther
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? if so, where and when?
Your Skin
What are your skin concerns?*
What would you say your skin type is?*

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
What is your skin complexion?*

LightMediumOliveDark
Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO
Have you used any of these products in the last: (Needs to be avoided before IPL to prevent complications)*

Tretinoin (15 days)Retin-A (7 days)Lactic, glycolic or salicylic acid products (7 days)Waxing, tweezing or used bleaching (14 days)Microdermabrasion/Chemical Peel (4 weeks)Laser treatments (4 weeks)Accutane (12 months)Prescribed topical cream (Please specify below)Other (Please specify below)None
Please specify which product or type, if you answered YES to the question above.
Please check any medications that you are currently taking:*

AntibioticsAnticancer drugAntidepressantsAntihistaminesAntihypertensivesAntiparasiticsNoneOther
I understand that if I'm unable to receive the IPL treatment because I have received any of the treatments/used products/medications above, I will be charged a last-minute cancellation fee of $50. NO EXCEPTIONS.
Females Clients
Are you pregnant or breast-feeding?*

YESNO
I do hereby agree to the following. I am allowing ILLUME SKIN SPA to take photos of my treatment and/or treated areas to be used to the purpose of monitoring my progress/use on ILLUME SKIN SPA website. I understand that my identity will remain anonymous.*
CANCELLATION POLICY*

I AGREE THAT A 48-HOUR NOTIFICATION IS REQUIRED TO AVOID A $50 CANCELLATION FEE OR A $50 RESCHEDULING FEE. I UNDERSTAND THAT IF I AM 10 MINUTES LATE FOR MY APPOINTMENT IT WILL BE CONSIDERED A NO-SHOW AND THE CANCELLATION FEE WILL BE APPLIED. I AGREE TO THIS POLICY AND CONSENT THE SPA TO CHARGE MY CARD ON FILE THAT WAS PROVIDED WHEN BOOKING.
I understand that scarring, which can be hypertrophic or even keloid, can occur. Other known complications of this procedure include blisters, reddening, pinpoint pitted scars, bruising, superficial crusting, burns, pain, and infections. These side effects are usually temporary, lasting from five to ten days but can be permanent as well. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results. Most patients require a number of treatments over several months with gradual results occurring over this time. Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received. I have read and understand the Pre and Post-Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of scarring, and other side effects and complications such as hyper pigmentation, hypopigmentation, and other skin textural changes. I release Illume Skin Spa and specific technicians from liability associated with this procedure. I certify that I am a competent adult of at least 18 years of age.
Signature*

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Illume Skin Spa

Your Medical History

Your Skin

Females Clients