IPL Consultation Form

Full Name *

First Name

Last Name

Are you happy for us to share your before and afters on social media? *

Yes

No

Treatment requested? *

Vascular

Pigmentation

Rejuvenation

Acne

Areas to be treated

Full Face

Nose/Cheeks

Half Face

Skin Spot

Full Face, Neck and Décolletage

Nose

Chest

Hands

Neck

Cheeks

Please select any of the following if applicable to you *

Pregnant or planning

Skin Pigmentation Disorders (Melasma, Vitiligo)

Diabetes

Lymphatic/Immune Disorders

Lupus

Depression/Anxiety

High Blood Pressure

Sun tanned/Solarium/Fake Tan

History of Cancer (Chemo/Radio Therapy)

Epilepsy

History of Keloid formation/scarring

Hepatitis/HIV

Thyroid Condition

Psoriasis/Eczema/Allergies

Herpes (Shingles/Cold Sores

Photosensitive Conditions

Have you used any of the following oral/topical medications in the past 3 months? *

St Johns Wort

Antibiotics

Roaccutane

Oral/Topical Steroids

No, none of the above

Do you currently have fake tan or an active tan fro the sun within 2 weeks old? *

YES

NO

Informed Consent for IPL Treatment *

The information I have given is correct to my knowledge and I have not withheld any medical state or condition. I will inform that the IPL operator before treatment if there has been any change. I understand that the results from this treatment vary considerably and small percentage of people will not respond satisfactory 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 and fake tan on the treated area for the duration of the treatment (and for up to 3 weeks afterwards) or use high sun protection factor to avoid sun damage. I understand that there may be short term side effects such as reddening, bruising, swelling, mild burning or blistering, hyperpigmentation (darkening of the skin), hypo pigmentation (lightening of the skin), as well as rare side effects such as scarring and permanent discolouration. I understand that there are certain risks associated with IPL and they include but are not limited to redness, localised swelling and mild tenderness. Although rare, adverse affects such as light burns, blisters and bruisers may occur. On occasion, IPL treatment may cause pigmentation changes to the skin. I understand that I must wear protective eye wear to prevent damage from the light. I understand no waxing or plucking on the area is to be done 3 weeks before treatment. I understand there have been no guarantees made to me and results of hair removal are not 100% permanent. I acknowledge to follow my IPL clinicians advice pre and post care

PLEASE TICK BOX TO INDICATE YOU UNDERSTAND AND ACCEPT THE INFORMATION CONTAINED