LED Photo-therapy Assessment Form

LED Phototherapy Assessment Form
Full Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Mobile Number*
Format: (00000)000000.
E-mail*
Next of Kin*

NameRelationship
Next of Kin Contact Number*
Format: (00000)000000.
PART ONE:

Assessment:
There are some circumstances and medical conditions in which Dermalux LED Phototherapy may prove to be unsuitable. Please answer the following questions below. A positive answer may prevent you from having the Dermalux treatment, however, further discussion with the ReNu Doctor would be required.
Do you currently have or have ever had any of the following (please tick)*

Epilepsy or Seizures Triggered by LightEye Disease or ConditionsPorphyria Metabolic DisordersLight Induced HeadachesSystemic Lupus ErythematousAre you Pregnant?Photosensitive EczemaHypomelanism (Albinism)Polyphonic Light EruptionRecent Eye Treatments (within 6 months)
* as cancer diagnosed within the previous six months, recurrent, regionally advanced or metastatic cancer, cancer for which treatment has been administered within six months, or haematological cancer that is not in complete remission.
Do you have any medical conditions including allergies? please specify below
Are you taking or applying topically any prescription medications? Certain medications can induce photosensitivity and may be contraindicated for the Dermalux treatment. It is important that you specify all.
*

Have you had a self-neutralising peel treatment in the last 24 hours?Have you started using any new skin care products in the past month?Are you currently taking St. John's Wort or other Herbal Remedies?Do you Smoke?Do you have outdoor lifestyle / activities?Do you use sunbeds?
Have you undergone any cosmetic/aesthetic procedures in the last 7 days? If YES please specify.*
Use this field to add any additional information / Message the ReNu Team
PART TWO:

CLIENT CONSENT:
Please read the following statements and confirm your consent to treatment*

I confirm that I have answered all the questions to the best of my knowledge and understand that withholding necessary information about my health and medication may increase my risk of possible side effectsI will inform my practitioner before every treatment if there has been aby changes to my circumstances or medication I may be taking.I understand that the Dermalux system has not been tested on pregnant women and therefore the risk to the foetus or pregnant women is unknown.I understand the benefits and likely clinical outcome of the Dermalux treatment and that multiple treatments are necessary to achieve optimal results.I acknowldge that no written or verbal guarantee, warranty or assurance has been made to me regarding the outcome of the procedure.I agree that i have read and understood all the information provided. My questions have been answered satisfactorily and i have made an informed decision to receive the dermalux treatment.I have been informed about the nature of the treatment, including its purpose, duration and expected outcomes.I understand that post-treatment care instructions provided to me and agree to follow them to ensure the best possible outcome.I understand that if I have further questions or concerns, I can contact the ReNu Dr at any time.I understand that although adverse events are rare, they do occur. If you experience ant sort of side-effect or adverse reaction following a Dermalux treatment you should contact the ReNu Dr. Either by email info@renumedicalaesthetics.co.uk or calling/texting +44 7950486352
Your personal data: We value your privacy. Your data will be used for treatment, communication, and compliance with legal obligations. We ensure that your data is secure and may be shared with healthcare providers or authorities when necessary.
*

I understand that my personal and medical information will be kept confidential and stored securely , in accordance with applicable data protectionI understand that photgraphic records will be stored and may be used for marketing purposes
Client Signature
Should be Empty:

LED Phototherapy Assessment Form

PART ONE:

PART TWO: