IPL/RF/SHR/ELIGHT Consultation Please complete the following information to maximise the effectiveness of the treatment and ensure your safety. Please answer all questions to your best ability and sign below. All information given is treated as confidential. Name: …………………………………………………………... Date: ….... /….…/………… Address:……………………………………………..Date of Birth:……/….…/……… Suburb:……………………………………………………………City:……………………… Telephone: Work: ………………Home: ……………… Mobile……………………………… Email address: …………………………………………………………………………………… Where did you hear about us? …………………………………………………………………… Areas to be Treated? Hair removal……………………………………………………………………………………. Pigmentation……………………………………………………………………………………. Veins……………………………………………………………………………………………. Medical Background Are you currently under a doctor’s care? Yes/No If, yes, for what?………………………………………………………………………………………. Have you been treated with hormone medication Yes/No If yes, indicate the specific hormone medication…………………………………………………... Please list any prescription and non-prescription medication you are taking including anything topical or herbal ………………………………………………………………………………………………….………..……………………………………………… Have you had surgery in the last 6 months? Yes/No If yes, please explain………………………………………………………………………… Are you sensitive to any soaps or lotions? Yes/No Does your skin get blotchy, red or irritated easily? Yes/No Have you had significant sun exposure in the last 6 weeks? Yes/No Have you waxed the areas to be treated within the last month? Yes/No Do you use sun beds or self-tanning products? Yes/No Do you have tattoos or permanent makeup in areas to be treated? Yes/No Are you currently pregnant or trying to conceive? Yes/No Client Signature: ………………………………………… Date:………………. Name: ………………………………………………………… Date: ……………………
Transcript
IPL/RF/SHR/ELIGHT Consultation
Please complete the following information to maximise the effectiveness of the treatment and ensure your safety. Please answer all questions to your best ability and sign below. All information given is treated as confidential.
Name: …………………………………………………………... Date: ….... /….…/………… Address:……………………………………………..Date of Birth:……/….…/……… Suburb:……………………………………………………………City:……………………… Telephone: Work: ………………Home: ……………… Mobile……………………………… Email address: …………………………………………………………………………………… Where did you hear about us? ……………………………………………………………………
Areas to be Treated? Hair removal……………………………………………………………………………………. Pigmentation……………………………………………………………………………………. Veins…………………………………………………………………………………………….
Medical Background Are you currently under a doctor’s care? Yes/No If, yes, for what?………………………………………………………………………………………. Have you been treated with hormone medication Yes/No If yes, indicate the specific hormone medication…………………………………………………... Please list any prescription and non-prescription medication you are taking including anything topical or herbal ………………………………………………………………………………………………….………..……………………………………………… Have you had surgery in the last 6 months? Yes/No If yes, please explain………………………………………………………………………… Are you sensitive to any soaps or lotions? Yes/No Does your skin get blotchy, red or irritated easily? Yes/No Have you had significant sun exposure in the last 6 weeks? Yes/No Have you waxed the areas to be treated within the last month? Yes/No Do you use sun beds or self-tanning products? Yes/No Do you have tattoos or permanent makeup in areas to be treated? Yes/No Are you currently pregnant or trying to conceive? Yes/No
Have you ever had any of the following treatments: Roaccutane Yes/No Any other cosmetic procedure Yes/No If yes, what and when?…………………………………………………………..
Have you ever experienced or been treated with/for the following? Skin Cancer Yes/No Irregular periods Yes/No High Blood Pressure Yes/No Cancer Yes/No Polycystic ovaries Yes/No Heart Problems Yes/No Cold sores Yes/No Birth control pill Yes/No Haemophilia Yes/No Diabetes Yes/No Menopause Yes/No Anti coagulant Yes/No Epilepsy Yes/No Thyroid Yes/No Keloid Yes/No Aspirin Yes/No Anti-inflammatory drugs Yes/No If yes, to any of the above, please explain and include dates …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Note: Any changes to medical history or medications must be notified Client Signature: …………………………………………. Date: …………………………..
Name: ……………………………………………………….. Date: ……………………………
I…………………………………………………duly authorise staff of …………………….to perform hair removal / skin rejuvenation/ pigmentation reduction and / or red blood vessel reduction procedures using Pulsed Light methods. I understand that this is a relatively new medical cosmetic procedure and that long-term studies are ongoing. Past studies indicate that this is an alternative method to removing unwanted hair / skin rejuvenation / pigmentation reduction and / or red blood vessel reduction and that results can vary according to skin and hair type as well as the medical condition of the client. I am aware that multiple treatments may be necessary to achieve satisfactory results. Skin pigmentation procedures need a doctor’s approval prior to commencing treatment. I have been advised of the following possible risks of Pulsed Light treatments: The treatment may not produce permanent hair removal /skin rejuvenation /pigmentation or red blood vessel reduction. Due to the nature of this treatment an exact result cannot be predicted and I acknowledge that no guarantees have been made to me as to the results that may be obtained. Possible side effects of the area can include mild discomfort, swelling and colour changes may develop. Colour changes such as hyperpigmentation (brown /red discolouration) or hypopigmentation (skin lightening) may occur in treated skin. This may take several months to return to normal. Skin must be protected from the sun for several weeks before and after treatment. Unprotected sun exposure in the weeks following treatment may worsen a condition that has hyperpigmentation. If the client has used oral isotretinoin (Accutane) they must wait six months after this treatment ends before starting laser treatments. Blistering and mild crusting of the skin may occur. Scarring is a rare possibility but it has occurred in less than 1% of the treatment population. Cold sores (Herpes simplex virus) may become active due to high light exposure in those prone to them. It is recommended that Valtres@ or Zovirax be taken as prescribed to avoid an outbreak. Client must use proper eye protection as recommended by the Technician.
My questions regarding this procedure have been answered to my satisfaction. I accept all risks of treatment and agree to provide aftercare as directed by this clinic. I consent to photographs for the purpose of monitoring response to therapy.
Name: ………………………………………………….. Date: …………………………………. Health assessment ( ) Sun issues ( ) Treatment process ( ) Hyper / hypo pigmentation ( ) Hair growth cycle ( ) Fitzpatrick skin type ( ) Series of treatments and maintenance sessions ( ) Home care ( )
Concerns:
Test pulses date: / / Skin type area Settings used
BEFORE AND AFTER TREATMENT ADVICEHOW TO PREPARE FOR YOUR SHR TREATMENT:
So, you’re considering SHR hair removal, great! There’s no need to deal with burns from wax, swelling from plucking or cuts and razor burn from shaving, anymore. Laser hair reduction is a fantastic option for permanent or long term hair removal. It’s a completely simple and easy alternative to the daily or weekly hair removal regimes.
SHR hair removal uses focused powered light to target the pigment and destroy the follicle.
How Do You Prepare?
Don’t tan or use sunless tanners for at least 2 weeks before your treatment. Do not wax or pluck the area of treatment, these can damage the follicles and area that you will need to treat so avoid
it as well. Shave a few days before your treatment, you don’t want to have too much hair, but you also want some to be showing
on the surface only so it can be easily targeted. Clean the area and don’t apply any lotions, makeup or deodorants of any kind to the area. Confirm with your doctor if any medication you are on is or isn’t photosensitive.
SHR AFTERCARE ADVICE:
Put on some sunscreen to cover that sensitive skin. Lasered skin is vulnerable to direct sunlight and may be prone to darkening. This is especially important in those with dark skin.
Avoid heat treatment like hot showers, steam rooms and sauna for at least 24-48 hours. Stay away from laser hair removal if you are on any sun sensitive medication. Please contact your doctor. Apply an ice-pack on the treated skin to reduce any pain and you can also use an ice-pack pre-treatment to
numb the skin, much like a local anaesthetic. With the exception of mineral make up which can be used post treatment, avoid any make up for at least a
day. Use sun screen with SPF 15, 20 or 50 and above. Avoid waxing, tweezing as for the laser hair removal needs intact hair follicles to be effective. Before hair laser removal you should avoid tanning your skin. Tanned skin increases skin tone. Darker skin
absorbs most of the IPL energy making hair removal difficult. Make sure to adequately space out laser hair removal sessions. Ideally, 4-12 weeks is advised. If you are going to get your underarms done, organize for an early morning treatment to avoid deodorant and
perfume use before the procedure. Avoid perfume, deodorant for at least 24-48 hours. Avoid scented soap (QV and goats milk is advised) 24-48 hours. Your skin may be sensitive so it would be advisable to wear loose fitting clothing in order to let the area breathe and
have as little rubbing as possible Another tip is that you may want to buy a soothing cream to help with any irritation, this helps speed up the recovery of
the skin to ensure the sensitivity and irritation goes away quicker. Aloe Vera would be recommended.
