Laser IPL Consultation Form

Laser IPL Consultation Form

YOUR DETAILS

GP DETAILS

EMERGENCY CONTACT

TREATMENT INFORMATION

LIFESTYLE & MEDICAL HISTORY

Please answer the following. If you don't understand or recognise the condition, select "Not Sure".
If you answered yes to any of the above, or thing there is any other information we should know about, please enter here. If you're not sure whether it's relevant, please include it anyway.

YOUR SKIN

DECLARATION

The information I have given is correct to the best of my knowledge, and I have not withheld any known medical state or condition. I will inform the IPL/Laser operator before treatment if there has been any change (for example in medications taken). I understand that the results from this treatment vary considerably and a small percentage of people will not respond satisfactorily to treatment. I understand multiple treatments are necessary to achieve satisfactory results. I understand there is no guarantee of permanent results and maintenance treatments may be necessary. I understand that I must avoid sun exposure on the treated area for the duration of the treatment (and for up to 1 month afterwards) 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 reddening, bruising, swelling, mild burning or blistering, hypo- pigmentation, (lightening of the skin) or hyper-pigmentation, (darkening of the skin), as well as rare side effects such as scarring and permanent discolouration. I understand that pigmented areas caused by sun damage may initially turn darker. This will be followed by ‘micro- crusting’ of the lesion, after which it should flake away leaving an area without excess pigmentation. I understand that I must wear protective eye goggles to prevent damage from the light. I certify that I have read and understood all the information and my questions have been answered satisfactorily before signing this consent form. I consent to the terms of this agreement.
Please just use the tick box above if you are unable to provide a signature

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