Laser / IPL Consultation Form

Section 1: Client information

Surname

Name

Title

Date of birth

Day

Month

Year

Home phone no.

Mobile phone no.

Email

Name and phone number of emergency contact

Ethnic origin

Interest

Section 2: Requested treatment

Other (please specify)

Body area(s)

Section 3: Lifestyle and medical history

Please CHECK OR CROSS the box as appropriate. If you do not understand or recognize the condition, discuss it with your laser / IPL operator.

Allergies

Units of alcohol per week

Helpful comments

Section 4: Medications and recent treatments

Are you currently taking any medications or dietary supplements?

Not

That

Please list condition and medications

Are you currently using/have you used any of the following in the last 6 months?

Comments

Are you recovering from any major medical treatment or photodynamic therapy (PDT) in the last 6 months?

Not

That

Skin disorder/disease

That

Not

Previous laser or IPL treatment

That

Not

What products do you use on your skin?

Please INDICATE how your skin reacts to exposure to midday summer sun without sunscreen:

Skin type 1 – Always burns, never tans

Skin type 2 – Burns easily, eventually gets a moderate tan

Skin type 3 – Sometimes burns, gets an average tan quickly

Skin type 4 – Rarely burns, gets a deep tan quickly

Skin type 5 – Very rarely burns, permanent tan

Skin type 6 – Never burns, permanent tan

Do you currently have a fake tan?

How long ago was the last time you were exposed to UV rays?

Have you ever used injections / complexion enhancers / Melanotan?

That

Not

What are your goals/expectations from treatment?

Where did you hear about the clinic?

Informed consent for IPL/Laser treatment

Please read this consent form and CHECK each box to confirm that you understand and accept the information provided here.

The information I have provided is correct to the best of my knowledge and I have not concealed any known medical conditions.

I will inform the IPL/Laser operator prior to treatment if there is any change (e.g. in medication intake).

I understand that the results of this treatment vary considerably and that a small percentage of people will not be satisfied.

respond to treatment.

I understand that multiple treatments are required to achieve satisfactory results.

I understand that there is no guarantee of permanent results and that maintenance treatments may be required.

I understand that I must avoid sun exposure on the treated area for the duration of the treatment (up to 1 month).

after) or use a high sun protection factor to avoid sun damage. I understand that tanned skin cannot be treated.

I understand that there may be short-term side effects such as redness, bruising, swelling, mild burning or blistering,

hypopigmentation (skin lightening) or hyperpigmentation (skin darkening), as well as rare side effects such as

scars and permanent discoloration.

I understand that pigmented areas caused by sun damage may initially darken. This is followed by 'micro-crusting'.

lesions, after which they should peel off, leaving the area free of excess pigmentation.

I understand that I must wear protective glasses to prevent light damage.

I agree that my contact information may be used to inform about special offers and other information about the clinic and its

services that might interest me.

I confirm that I have read and understood all the information and that my questions have been answered satisfactorily before

signing this consent form. I agree to the terms of this agreement.

Client name

Date

Day

Month

Year

Client signature

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Pre-treatment checklist – To be completed by the operator (CHECK to confirm that the points have been considered)

Additional questions / comments