ipl client history v1_7

8/6/2019 IPL Client History v1_7

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IPL (Intense Pulsed Light)

Consultation Form

DATE OF CONSULTATION: / /

1) Contact Information

Title: Name: Date of Birth: / /

Address: Tel (H):

Tel (W):

Tel (M):

Postcode: Do you prefer written contact by email or post?: Email / Post

Email address:

Emergency Contact Name: Tel:

How did you hear about us?

Current GP:

2) Your Current Concerns

There is a full health questionnaire on the next page but please tell us a little about why you would like our help.

a) What type of problem(s) are you consulting for today?

Sun spots

Wrinkles

Distended blood vessels (spidery red spots)

Flushing of the skin

Large pores

Unwanted / Excess hair

b) How long have you noticed these problems, or how old were you when they started?

c) Are these problems currently getting worse? YES / NO

d) Have you already had treatment for these problems? YES / NOIf yes, please write below which treatments and when you received them:

e) Please tick your skin type below (when exposed to the UK sun without protection for about 1 hour)

I Always burns, never tans II Always burns, then sometimes tans III Sometimes burns, then usually tans IV Always tans, Mediterranean, Hispanic V Asian, Middle Eastern VI Black

f) Do you suffer from claustrophobia? YES / NO

V1.7 03/05/2011 Review Date: 02/05/2012Page 1 of 8

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++LLASERASER CCLINICLINIC


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3) Health Questionnaire

If you answer YES to any of these questions please give FULL details in the space at the bottom of the page,including dates of any treatments and names of any medications. If you need more space please use the backpage.

Questions Please circle1. Do you have any medical or health problems? YES / NO

2. Do you now or have you ever suffered from any skin conditions including: skincancer, eczema, psoriasis, keloid scars, vitiligo, septicemia, easy bruising,dermatitis, dark spots after pregnancy, burns, skin grafts or acne?

YES / NO

3. Have you had any sun exposure or used any sun beds / tan accelerators in the last6 weeks, or are planning to use any of the above?

YES / NO

4. Are you taking any prescribed medication, either long or short term? YES / NO5. Do you apply any medication or other creams to your skin? YES / NO6. Are you taking any vitamins, herbal, homeopathic, Chinese remedies or medication

bought over the counter?YES / NO

7. Do you consume more than 1 or 2 units of alcohol daily? YES / NO8. Do you wear contact lenses? YES / NO9. Have you ever had any form of cancer? YES / NO10. Do you have any allergies? Please include all allergies e.g. food, medication, etc YES / NO11. Have you ever had any cosmetic or other surgery or implants? YES / NO12. Do you have any hormone disorders such as thyroid problems, hirsutism or

polycystic ovarian syndrome (PCOS)?YES / NO

13. Have you had any facial treatments including peels? YES / NO14. Have you had Botox / Restylane / Sculptra or similar treatments? YES / NO15. Do you suffer from cold sores or shingles? YES / NO16. Do you suffer from epilepsy, depression, diabetes, liver or kidney conditions,

autoimmune diseases (e.g. Lupus, Rheumatoid arthritis) or any heart condition?YES / NO

17. Have you ever had any Intense Pulsed Light (IPL) or Laser treatment in the past? YES / NO18. Do you have any bleeding or clotting disorders? YES / NO19. Have you had any tattoos or permanent make-up anywhere on your body? YES / NO20. Do you have any other medical or health problems not listed here? YES / NO

Female clients21. Are you or could you be pregnant? YES / NO22. Are you breast-feeding? YES / NO

Client DeclarationI confirm that the information given on this form is compete and accurate

Signature of client: _________________________________________ Date: / /

Please add any details for YES answers below, with the relevant question numbersQuestion No Details



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TO BE COMPLETED BY CLINIC STAFF

4) Treatments and costs discussed

The treatment proposed is for: (please circle as appropriate)

Hair Removal Skin rejuvenation Vascular lesions Pigmented lesions Acne Other (________________)

Using the Lumenis ONE Intense Pulsed Light (delete if necessary)

This treatment will involve the therapist applying light to the skin in order to achieve the desired result

The treatment selectively destroys target chromophores (hair follicles, pigmented cells, abnormal vesselsor bacterial products) while minimising damage to the surrounding tissue

The area(s) to be treated is / are as follows: _______________________________________________________

__________________________________________________________________________________________

Costs agreed:

Medical consultation required? YES / NO

5) Medical Consultation Notes (if required)

Advice sought from Laser Protection Adviser? YES / NO (Copy of fax to be included in case notes)

Following this consultation and any LPA advice, my decision is that treatment SHOULD /SHOULD NOT proceed.

Please list any specific conditions to treatment below:



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WWESTESTWWALESALES AAESTHETICSESTHETICS ++LLASERASER CCLINICLINIC

6) Client Agreement to Treatment - Practitioner Statement

CLIENT'S FULL NAME: DATE OF BIRTH: SEX: M / F

I have explained the treatment to the client. In particular, I have explained (tick to confirm):

Hair removal may be permanent, but we cannot guarantee total hair removal and the results arevariable from person to person treatment does NOT carry a money back guarantee.

Laser / IPL treatment will not cure any underlying medical condition.

Conditions listed in the consultation form can make clients unsuitable for treatment.

The need to avoid sun or UV exposure for 4 weeks prior to AND after treatment and the need to use sunprotection of no less than SPF 30 on all exposed areas which are treated for at least one month.

Multiple treatments will be necessary to achieve optimal results the number of sessions required will bedependent on the individual's response typically 6 8 sessions for hair.

A patch test will be carried out prior to full treatment to determine any unusual reactions to treatment. This willbe reviewed after a minimum of 7 days.

I have also explained that serious but infrequently occurring risks include:

Pain, tenderness, reddening, burning, blistering, swelling and bruising or discolouration.

Hyper- or hypo- pigmentation of the skin which may take 6-18 months to resolve. This can be made worse andmore likely by sun or UV exposure.

In rare cases, permanent discolouration of the skin may occur.

Possibility of infection and permanent scarring to the treated area

I have discussed what the treatment is likely to involve, the benefits and risks of treatments and alternativetreatments (including no treatment) and any particular concerns of this client.The client has been provided with :

Client Guide Pre-treatment leaflet Aftercare leaflet

Signed: _________________________________________ (Therapist) Date/Time: ____________________

Name: __________________________________________

Statement by Interpreter (if required):I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/hecan understand.

Signed: ____________________________ Name: _________________________ Date/Time: ______________



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7) Client Agreement to Treatment - Statement of Client

You MUST take time to read the whole of this page carefully

You should have been provided with your own copy of this agreement to take away with you, if not ask for one now.If you have any other questions DO ASK - we are here to help you.

You have the right to change your mind at any time, including after you have signed this form.

I have agreed to the treatment described in this form

the nature and purpose of the treatment have been fully explained to me and I confirm that I have beeninformed of the risks and benefits of the treatment

all of my questions have been answered to my satisfaction

I confirm that I have been provided with a copy of this Consent Form, the Client Guide and Pre-treatmentand Aftercare information leaflets

I agree to comply with the requirements and recommendations of the clinic regarding my treatment and topay the fee of per treatment / per course of treatments (delete as appropriate)

I understand that the general medical council strongly advises that general practitioners are kept informedabout all treatments undertaken by their patients

I do / do not * wish my GP to be informed about my treatment

Declaration by client:

I have carefully read this form, the Client Guide and the pre- and post-treatment information leaflets.

I confirm that I understand the treatment and the risks and benefits, which have been explained to me

All of the information I have given is complete and accurate

I agree to pay the fees stated to me for this service

I hereby give my consent to the treatment.

Signed: ______________________________________________ Date/Time:____________________

Name (block capitals): ______________________________________________________________

Photographs

I do / do not (please delete as appropriate) give permission for 'Before' & 'After photographs and other audio-visual and graphic materials to be used by the clinic for treatment and internal training purposes.

I do / do not (please delete as appropriate) give permission for the above photographs to be used by the clinicmarketing or promotion purposes. Although the photographs or accompanying material will not contain my nameor any other identifying information, I am aware that I may or may not be identified by the photos.

Signed:_______________________________________________ Date/Time:____________________



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8) Initial Assessment Summary and Patch Test


PATCH TEST DETAILS

Site of Patch Test(s): ______________________________________________________________________________

Shots Sensation/10

Fluence: ______J/cm2 Wavelength:______nm Head size(s): S / L Pulse train: ___ _____








Immediate reaction:

Practitioner: ______________________ Practitioner's signature: _____________________ Date/Time: ____________

Post-treatment ins truction leaflet given?: YES / NO Review appointment made?: YES / NO

REVIEW APPOINTMENT Date: ______________

Client's Comments:

Practitioner's Assess ment:

ADVERSE EFFECTS?:

OUTCOME OF ASSESSMENT + PATCH TEST:

Proceed with treatment?: YES / NO


Medical history summary:

Allergies / sensitivities:

Medications:

Photosensitising?

Skin Type Hair Thickness Pigmentation System

I II III IV V VI Lumenis One IPL


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TREATMENT SHEET



Treatment No: __________Date of Treatment: ____ / _____ / _________

Confirmation of consentI confirm that there have been no changes in my medical history or in the medication I am taking since completing

my health questionnaire and my consultation. I consent to continuation of the treatment.

or (delete as applicable)

The following changes have occurred in my medical history or medication since my last treatment.

_________________________________________________________________________________

_________________________________________________________________________________

Signed: ______________________________________________ Date/Time: ________________

Problems / Adverse Reactions / Comments from the Previous Treatment

_________________________________________________________________________________

_________________________________________________________________________________

Healthcare Professional's statementI have confirmed with the client that he/she has no further ques tions and wis hes to proceed with the treatment.

Signed: ______________________________________________ Date/Time: ________________

Name: ______________________________________________

Skin Type Hair Thickness Pigmentation System Photo Taken

I II III IV V VI Lumenis One IPL YES / NO

TREATMENT DETAILS

Site(s) of Treatment(s): ____________________________________________________________________________

Treatment type: ________________________________________ Shots Sensation/10

Fluence: _____J/cm2 Filter:______nm Head size(s): S / L Pulse train: ____ _____




Practitioner's notes on treatment:


Post-treatment instruction leaflet given?: YES / NO Next appointment made?: YES / NO

Follow up Instructions:


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TREATMENT SHEET



Treatment No: __________Date of Treatment: ____ / _____ / _________

Confirmation of consentI confirm that there have been no changes in my medical history or in the medication I am taking since completing

my health questionnaire and my consultation. I consent to continuation of the treatment.

or (delete as applicable)

The following changes have occurred in my medical history or medication since my last treatment.

_________________________________________________________________________________

_________________________________________________________________________________

Signed: ______________________________________________ Date/Time: ________________

Problems / Adverse Reactions / Comments from the Previous Treatment

_________________________________________________________________________________

_________________________________________________________________________________

Healthcare Professional's statementI have confirmed with the client that he/she has no further ques tions and wis hes to proceed with the treatment.

Signed: ______________________________________________ Date/Time: ________________

Name: ______________________________________________

Skin Type Hair Thickness Pigmentation System Photo Taken

I II III IV V VI Lumenis One IPL YES / NO

TREATMENT DETAILS

Site(s) of Treatment(s): ____________________________________________________________________________

Treatment type: ________________________________________ Shots Sensation/10





Practitioner's notes on treatment:


Post-treatment instruction leaflet given?: YES / NO Next appointment made?: YES / NO

Follow up Instructions:

ipl client history v1_7

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