Body Works Consent Forms

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Gender*

I am interested In: (please check all that apply)*

When you sunbathe, how does your skin respond?*

Always burn, never tanUsually burn, tan with difficultySometimes burn, tan about averageAlmost never burn, tan very easily Rarely burn, tan easilyNever burn, always tan

Medical History: Check the appropriate box next to any condition for which you have been treated.*

ARE YOU CURRENTLY BEING TREATED FOR ANY CONDITIONS NOT LISTED? IF YES, PLEASE SPECIFY*

ARE YOU CURRENTLY TAKING ANY MEDICATIONS, INCLUDING HERBAL PREPARATIONS, MEDICAL PATCHES OR ASA? IF YES, PLEASE SPECIFY.*

DO YOU HAVE ANY ALLERGIES? IF YES, PLEASE SPECIFY.*

HAVE YOU EVER USED (OR ARE CURRENTLY USING) RETIN A OR GLYCOLIC ACID? IF YES, PLEASE SPECIFY.*

HAVE YOU EVER USED (OR ARE CURRENTLY USING) ACCUTANE? IF YES, PLEASE SPECIFY*

HAVE YOU EVER HAD A CHEMICAL PEEL? IF YES, PLEASE SPECIFY.*

HAVE YOU HAD ANY LASER TREATMENTS? IF YES, PLEASE SPECIFY.*

WHAT PRODUCTS ARE YOU CURRENTLY USING ON YOUR SKIN?*

DO YOU HAVE ANY DENTAL OR ACRYLIC IMPLANTS, CROWNS OR BRIDGEWORK? IF YES, PLEASE SPECIFY*

DO YOU HAVE ANY TATTOOS OR PERMANENT MAKEUP IN THE AREA TO BE TREATED?*

YesNo

DO YOU HAVE A PACEMAKER?*

YesNo

HAVE YOU EVER BEEN TREATED BY AN ENDOCRINOLOGIST (HORMONE IMBALANCE)?IF YES, PLEASE SPECIFY.*

DO YOU SUNBATHE OR USE SELF TANNING LOTIONS OR USE TANNING BEDS? IF SO, THEN HOW OFTEN?*

HAVE YOU EVER HAD GOLD THERAPY (USED FOR RHEUMATOID ARTHRITIS)?*

YesNo

ARE YOU CURRENTLY PREGNANT?*

YesNo

HAVE YOU HAD FILLER OR BOTOX/DYSPORT INJECTIONS IN THE AREA TO BE TREATED?IF YES, PLEASE SPECIFY.*

DO YOU HAVE ANY PARTICULAR SKIN SENSITIVITIES?*

PLEASE SIGN BELOW TO INDICATE ALL THE INFORMATION ON THIS FORM IS ACCURATE AND COMPLETE.*

I hereby authorize Body Works Day Spa & Yoga Studio’s supervision to perform Limelight IPL on me. I understand that this procedure works on promoting vibrant and healthy looking skin. I understand that multiple treatments are required and it is possible the result will be minimal or not help at all.

I am aware of the following possible experiences/risks:
DISCOMFORT – A slight warming sensation may be experienced during treatment.
REDNESS/SWELLING/BRUISING – Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.
SKIN COLOR CHANGES – During the healing process, there is a possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.
ITCHING/DRY SKIN – Treatment may result in itching and/or dry skin.
RED RASH/BUMPS – Red rash/bumps may appear after treatment. This resolves with time.
WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our office.
INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our office (516) 488-5573.
SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.
SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING - May increase risk of side effects and adverse events.
EYE EXPOSURE – Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.

I acknowledge the following points have been discussed with me:

Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me
Alternative treatments such as topicals, microdermabrasion, or surgery
Reasonably anticipated health consequences if the procedure is not performed.
Possible complications/risks involved with the proposed procedure and subsequent healing period

For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep Body Works Day Spa & Yoga Studio staff informed should I become pregnant during the course of treatment.

Photographic documentation will be taken.
I hereby authorize the use of my photographs for teaching purposes.

ACKNOWLEDGMENT
BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR LASER GENESIS TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.

Patient or Guardian Name*

Relationship)*

With your signature you agree to today and all future treatments of this service.

Signature*

IPL Health History / Consent Form

Patient Informed Consent Form