IPL/Laser Consultation-Kilkenny Beauty and Laser Clinic

Laser/IPL
Therapists Name if known

First Name Last Name
Date of appointment

Month Day Year
Date
Clients Name

First Name Last Name
Address

Street Address

Street Address Line 2

City County

Eircode
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
Area to be treated

Face Neck Chest Legs Back Underarm Bikini Forearm Abdomen Other
Which of the following treatments are you having done

Hair Removal Skin Rejuvenation Veins Acne Pigmentation
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

Yes No
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

Fever Cancer Hepatitis Fever contagious or infectious diseases Skin Diseases Undiagnosed lumps and bumps Localised swelling Hypersensitive skin Inflammation scar tissue Haematoma Sunburn Windburn Recent fractures Herpes or skin infections Loss of skin sensation Cardio conditions Recent surgeries Eczema Depression Taking prescribed medication or have been on prolonged medication in the last year Psoriasis Epilepsy Diabetes Already being treated by a GP or medical practitioner Pregnant Thyroid medication or thyroid imbalance Sun tan Fake tan Keloid scars Pacemaker Jaundice Metal pins and plates Melasma Moles Vitiligo Skin tags Cardiovascular Herbal 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

Latex Make up Other
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

Botox Fillers Permanent make up Implants Cosmetic injections
Have you recently had any of the following

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

Retinol Retin A Roaccutane Glycolic peels Accutane AHA Other peeling agent None
Have you ever had any of the following facial treatments

IPL Laser Microneedling Sugaring Microdermabrasion Chemical Peels micropigmentation Depilatory Cream Shaving Tweezing Bleaching Sclerotherapy Epilation Light treatments Cosmetic Surgery Mesotherapy None Other
If you ticked any of the boxes above please give details blanks
Date Of Previous treatment

Month Day Year
Date
Are you currently or have you in the last 3 years taken any of the following

High Doses of NSAIDS (Anti Inflammatory Drugs Ibuprofen Blood Thinner or Aspirin Anti coagulant medication Anti platelet drugs Steroids Immunosuppressive Drugs Other Medication None Other
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 HRT Taking Contraception Having menopausal Problems Or 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 treatment inform the therapist of all previous treatments on the area to be treated Shave any area to be treated for hair removal I have not had chemical peels , Botox or dermal fillers within 4 weeks of treatment I am not using st johns wort, anti coagulants, anti biotics, roaccutane or Gold medication Retin A should not be used for 2 weeks before treatment Seroid products should not be used for 2 weeks before treatment Sunbeds should not be used for 4 weeks before treatment False tan should not be used within 2 weeks of treatment and should be completely removed from the skin with no trace left Hair Removal from the root should be avoided for 4 weeks before treatment and discontinued after treatment ie waxing, tweezing Hair removal cream and bleaching should not be done within 24 hours of treatment Products containing alcohol such as toners should be avoided before treatment Avoid use of any chemicals on the skin prior to treatment Area should be freshly cleaned No 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:

Clear
Date

Month Day Year
Date
Any other treatment Notes
Consultation checked and Precare/Aftercare supplied to client. To be signed by your Therapist:

Clear
Jennifer Sweeney
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Laser/IPL

Jennifer Sweeney