IPL hair removal Consultaion Form

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Cons

hair removal

consultation form

IPL

to provide you with a very safe service with the best possible results please provide the following information

First Name

Email Address

Last Name

Date of Birth

Mobile Number

Address

Occupation

Family Doctor Name

Emergency Contact Name

Ethnic Background

Family Doctor Number

Emergency Contact Number

Areas of Concern

What method of hair removal do you currently use (if applicable tick below)

Tweezing

Dipilatory Creams

Shaving

Waxing

Electroysis

Other

How often is this method used

Is there a family history of superfluous (excessive) hair?

Yes

Details

When did you notice excess hair development?

Details

Do you have any current or chroice medical illnesses?

Yes

Details

Are you currently under a doctos care?

Yes

Details

Are you taking any photosenstizing medications? (ie. anti depressants, St. Johns Wart, etc

Yes

Details

Permaent make up, implants or tattoos?

Yes

Details

Botox, dermal fillers etc or chemical peels (within 12 months)

Yes

Details

Do you smoke?

Yes

Do you drink?

Yes

Do you have any allegies?

Yes

If so, how many a day?

If so, how many a week?

If so, please list

Medical Informed Consent

I consent and authorise Dermal Remedy to perform IPL hair removal treatments on me. I understand the following points and I will have had the opportunity to ask questions during my consultation.

In relation to IPL hair removal treatments, I have been advised as follows:

1. Treatment are successful on most clients but my individual results cannot be guaranteed

2. Most clients require 8-10 treatments to achieve up to 80% hair reduction, some may require more. Hair loss is variable and individual results depend on may factors, thus it is extremely difficult to advise on exact number of treatments required.

3. Light blonde, grey, red or white hair does not respond to IPL treatment

4. Fine facial hair takes longer to respond to treatment than hair in other areas and will require additional treatments

5. Darker skin type clients will require additional treatments

6. Exposure to UV Rays will compromise my treatment, therefore I will use SPF 30+ sunscreen

7. Growth of dormant follicles that may be triggered by hormonal changes (eg. stress, illness, medications, pregnancy, trauma or other causes) can stimulate future hair growth

8. Not following the program regarding timing of treatments will reduce efficacy of treatment

Risks associated with IPL hair removal treatments. Please tick that you have read and understand the following:

Pigment changes (light or dark spots on the skin) lasting 1-6 months. Freckles may temporarily or permanently disappear in treated areas. Other potential risks include crusting, itching, pain, bruising, pimple like bumps, dry skin, hypopigmentation (lightening of the skin), hyperpigmentation (darkening of the skin), blistering, burns, infection, scabbing, swelling, a very small risk of scarring.

A failure to achieve desired results

Allergic or delayed infammatory reactions can develop. A patch test is performed to ascertain reaction of the skin to IPL

Intense Pulse Light Systems can cause eye injury and protective eyewear must be worn during treatment

Prior to initiation of treatment, any pigmented lesions should be correctly identified by a physician to be benign and recommended for light based treatment. A medical certificate to this effect is required.

I consent to photographs taken to evaluate effectiveness. Photographs revealing my identity will not be used without consent.

I understand the sensation of light based treatments is sometimes uncomfortable and feels like a flicking sensation.

I am 18 years of age (otherwise parent or gaurdian to sign)

I will advise Dermal Remedy of any changes that occur during my treatment that can increase potential risks or reduce efficacy

I also understand that there will be no refund for any performed services

In relation to my initial and all subsequent treatments I advise that; Please tick that you have read and understand the following:

I have not had unprotected sun exposure (including fake tan) in the last 4 weeks

I have not used mechanical epilation, waxed or tweezed

I have no history of seizurs and I have disclosed all known allergies (eg. Latex, etc)

I am not taking medication causing photosensitivity (presciption/non presciption) eg. St. Johns Wart, Anti coagulants, etc.

I do not have a history of keloid + hypertrophic scar formation

I do not have active infections+immunosuppression

I do not have open lesions in the areas to be treated

I do not have herpes I or II in the areas to be treated

I have not used Tretinoin (Retin A, Renova) within the last 2 weeks

I have not had laser resurfacing in the last 6 months on the areas to be treated

I have not had a chemical peel within the last 4 weeks

I have not used oral isotretinoin/Accutane within the past 6 months

I have advised Dermal Remedy if I am diabetic

I am not pregnant, do not have hormonal imbalances or taking any medication which may affect treatment outcomes

I have read the pre and post care on Dermal Remedys webiste. I agree to adhere to all these recommendations

If my treatments are related to facial hair removal, I have been advised of the possibility of on going long term maintenance.

Consent

I hereby give my concent + authorization, and voluntarily release Dermal Remedy from any claims implied or stated that I have or may have in the future with this treatment, regardless of result. I am stating that the treatment and precausions above have been explained to me in detail and that I fully understand. If I am under the care of a physician, I have discussed the treatment plan with my physician for prior approval.

I declare that the information I've provided is accurate + complete

Your Signature

Today's Date

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