IPL/Laser Consultation-Kilkenny Beauty and Laser Clinic

Laser/IPL
Therapists Name if known

First NameLast Name
Date of appointment

MonthDayYear
Date
Clients Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Eircode
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth
Area to be treated

FaceNeckChestLegsBackUnderarmBikiniForearmAbdomenOther
Which of the following treatments are you having done

Hair RemovalSkin RejuvenationVeinsAcnePigmentation
What are your main concerns
List the skincare products you are using and how often you use them
Cleanser: Type
Toner:Type
Moisturiser: Type
Eye Cream/Gel: Type a label
Serum:  Type a label
Exfoliator: Type a label
Do you use daily Sun protection factor  Type yes or no
If yes list product and factor Type a label
Are you taking any skin supplements?  Type a label
Have you had any issues with your skin in the past?  Type a label
Are you using any other products on your skin not mentioned above Type a label
Do you or have you ever used sunbeds
If you answered yes to the above question when was the last time you used a sunbed blanks
How would you best describe how your skin reacts in sunlight
Which of the following best describes your parents skin
Have you recently used Self tanning lotions or creams

YesNo
Does your Lifestyle involve you to
How much water do you drink daily blanks
Do you Smoke
If you answered Yes to the above question Ensure you do not smoke within 2 hours of vein treatment.
Have you Ever had/Do you have any of the following

FeverCancerHepatitisFevercontagious or infectious diseasesSkin DiseasesUndiagnosed lumps and bumpsLocalised swellingHypersensitive skinInflammationscar tissueHaematomaSunburnWindburnRecent fracturesHerpes or skin infectionsLoss of skin sensationCardio conditionsRecent surgeriesEczemaDepressionTaking prescribed medication or have been on prolonged medication in the last yearPsoriasisEpilepsyDiabetesAlready being treated by a GP or medical practitionerPregnantThyroid medication or thyroid imbalanceSun tanFake tanKeloid scarsPacemakerJaundiceMetal pins and platesMelasmaMolesVitiligoSkin tagsCardiovascularHerbal remedies
If you ticked any of above give details Type a label
Are you currently being treated for a condition not listed blanks If so what?blank
Are you prone to keloid scarring
Are you allergic to any of the following

LatexMake upOther
If you ticked any of above give more details blanks .
Are you prone to Post Inflammatory Hyperpigmentation (dark marks after inflammation on the skin)
Do you have any of the following
Do you have any of the following

BotoxFillersPermanent make upImplantsCosmetic injections
Have you recently had any of the following

Local anaestheticGeneral Anaesthetic
Do You or have you used any of the following

RetinolRetin ARoaccutaneGlycolic peelsAccutaneAHAOther peeling agentNone
Have you ever had any of the following facial treatments

IPLLaserMicroneedlingSugaringMicrodermabrasionChemical PeelsmicropigmentationDepilatory CreamShavingTweezingBleachingSclerotherapyEpilationLight treatmentsCosmetic SurgeryMesotherapyNoneOther
If you ticked any of the boxes above please give details blanks
Date Of Previous treatment

MonthDayYear
Date
Are you currently or have you in the last 3 years taken any of the following

High Doses of NSAIDS (Anti Inflammatory DrugsIbuprofenBlood Thinner or AspirinAnti coagulant medicationAnti platelet drugsSteroidsImmunosuppressive DrugsOther MedicationNoneOther
If You have ticked any of the above please give details here blanks
Have you used Hair removal methods in the last 4 weeks on the area to be treated
Have you been in the sun recently
If you answered yes above. Give details Type a label
Female Clients only:Are you currently

Taking HRTTaking ContraceptionHaving menopausal ProblemsOr recently made changes to contraception
If you ticked any of above please give details blanks
What are your expectations from this treatment
Pre Treatment check list

Cover areas to be treated from direct sunlight from 48 hours before treatmentinform the therapist of all previous treatments on the area to be treatedShave any area to be treated for hair removalI have not had chemical peels , Botox or dermal fillers within 4 weeks of treatmentI am not using st johns wort, anti coagulants, anti biotics, roaccutane or Gold medicationRetin A should not be used for 2 weeks before treatmentSeroid products should not be used for 2 weeks before treatmentSunbeds should not be used for 4 weeks before treatmentFalse tan should not be used within 2 weeks of treatment and should be completely removed from the skin with no trace leftHair Removal from the root should be avoided for 4 weeks before treatment and discontinued after treatment ie waxing, tweezingHair removal cream and bleaching should not be done within 24 hours of treatmentProducts containing alcohol such as toners should be avoided before treatmentAvoid use of any chemicals on the skin prior to treatmentArea should be freshly cleanedNo Deodorant or perfume should be used on the area
Tick below to agree to the following

I agree to Kilkenny Beauty and Laser Clinic using my details for the purposes of this treatment
Tick below to agree to the following

I agree to Kilkenny Beauty and Laser Clinic using my details to inform me of special offers and updates
Tick to agree with the following

I have answered all of the questions
I Confirm to the best of my knowledge that the answers that I have given here are correct and I have not withheld information that could be relevant to my treatment. I have been informed about the expected results and expected after effects of treatment I understand that following treatment depigmentation of the area is possible causing the skin to appear paler or hyperpigmentation is possible causing the skin to appear darker. in most cases this will return to normal but the clinic is unable to guarantee that this will be so. As with all treatments of this type scarring is possible but extremely rare . I understand that extent of Hair removal and improvement in skin condition varies from person to person. I unerstand that for hair removal it will take 7-21 days after treatment for hair to fall out, these will only be hairs that were treated in the active growing phase. I understand that I cannot be exposed to sun or go on sunbeds for 4 weeks. I understand that a course of spaced out treatments will be needed. I have been given my pre care advice and have filled this consultation truthfully and so release the establishment Kilkenny Beauty and Laser Clinic of any claim I have or may have in the future. I agree to follow all aftercare which will be given to me by my Therapist. Signature:
Date

MonthDayYear
Date
Any other treatment Notes
Consultation checked and Precare/Aftercare supplied to client. To be signed by your Therapist:
Jennifer Sweeney
Should be Empty:

Laser/IPL

Jennifer Sweeney