Permanent Hair Reduction Consent Form

Last name

Today’s date:

Mobile number

Telephone number

Physical address

Address 2 (optional)

Suburb (optional)

City (optional)

State (optional)

Postcode (optional)

Date of birth

Gender

Female

Male

Self-described

Prefer not to say

Referred by

What is the purpose of your visit today? (optional)

What do you hope to achieve if treatment is possible? (optional)

Have you had advanced aesthetic treatment before?

injections

skin treatments

laser

peels

None of the above

If YES, What procedure/s? (optional)

Where/Who carried out the procedure? (optional)

Medical questionnaire (all information given will remain confidential) Are you affected by any of the following conditions?

Polycystic Ovaries/Endometriosis

Diabetes

Epilepsy/seizures

Hepatitis

Allergies

Eczema / Psoriasis

Communicable disease

Viral infections (shingles/cold sores)

Skin Diseases

Scars Yes

Circulation problems/Bruise easily

Keloid scars

Haemophilia/bleeding disorders

None of the above

If yes to any of the above, please specify details: (optional)

Are you affected by any of the following conditions?

Do you have any pigmented lesions, moles, birthmarks or vitiligo?

Have you or any family member ever been diagnosed with Melanoma?

Have you ever had any form of skin cancer?

Have you taken, or are you taking birth control pill or oral / injectable hormones?

Are you, or do you think you might be pregnant?

Are you breastfeeding?

Are you a smoker?

Have you ever taken Roaccutane /Accutane/ Isotane ? (acne medications)

Currently or in the past used Retin A ? (prescribed creams for acne)

Do you have any form of immune deficiency?

Do you have any metal pins or plates anywhere in the face or body?

Have you had, or are you experiencing any form of health problem?

Have you had, or are you about to have any medical treatment or surgery?

Are you taking any type of medication?

Do you currently suffer from, or have suffered from in the past: Depression / Body dysmorphia / Eating disorders / Claustrophobia ?

Do you have a pacemaker or electronic / metal medical devices fitted in your body?

None of the above

Permanent Hair Reduction Consent Form

I have been fully informed by the IPL clinician/staff member and understand the following conditions relating to IPL Hair Reduction.

I have answered all of the questions regarding my health and skin correctly and to the best of my knowledge, as I am aware that some ailments and medications can affect the healing of the skin and response to the IPL treatment.

It is my responsibility to ensure that I inform my IPL clinician if I began a course of medication.

The price options have been explained to me.

I understand that sun exposure and sunbeds in the treatment area are not permitted during my treatment course and the application of total sunblock must be used if exposure is unavoidable.

I understand that the last application of fake tan must be at least 2 weeks prior to treatment to ensure no residue is present on the skin.o Fake tan and natural tan will compromise my treatment, either by obliging the clinician to reduce the settings to accommodate the tan or by having to wait for the tan to fade, by which time the ideal hair growth cycle may be missed.

It is my responsibility to advise my laser clinician of any exposure to the sun or sunbed before and during my treatment course. I understand that failure to do so can have an adverse effect on my skin.

I am aware that no waxing, plucking, threading, or any other method that involves removing hair by the root, is unacceptable throughout my treatment course. Shaving is acceptable.

For optimum results, all treatments must be done within 2 weeks of first noticing new re-growth or within 3 months, whichever is sooner.

I have been advised of the approximate number of treatments for the area that I am interested in having done. However, I am aware that this treatment aims to provide permanent hair reduction and not permanent hair removal.

If the power is set lower at my request, I understand that the treatment may not be as effective.

I am aware that in rare cases, hair growth can be increased in areas adjacent to the treatment area. This is due to light-induced bio-stimulation. My hair may also become lighter, finer, and less obvious; and there may be a time when my results plateau and further treatment is deemed unproductive.

I am aware that I will need to be re-test patched on the area if I do not return to the clinic within a 6 month period, I also understand that I will need to have a test patch on any new area that I am considering for treatment.

Underlying or undiagnosed pigmentation conditions (i.e.: hormonal pigmentation) can be triggered or stimulated due to the nature of the treatment.

I have discussed and am aware of the possible side effects of IPL treatment as follows:

Redness, itching, and swelling are common side effects immediately after treatment and can sometimes occur for up to 2 weeks following treatment.
It is usual and even desirable that there may be a fine, superficial brown scale or gravel rash on the skin the next day. This takes anything from a few days to a couple of weeks before totally disappearing. Hyperpigmentation (increased browning of the skin) may occur especially in darker skin types and may take months before disappearing
Hypopigmentation (whitening of the skin) is rare, again more common on darker skin types and may take months to return to normal. In very rare instances, may be permanent.
Folliculitis (infected hair follicles) and acne can be stimulated with IPL light, especially on male beards, backs, and chests. Other treatment regions on females, as well as males, can also be affected.
Bruising and delayed bruising may occur post-treatment especially if the skin is susceptible to bruising easily. Applying Arnica cream to the area will accelerate healing.
In rare circumstances, it has been known for IPL hair reduction stimulate hair in surrounding areas. If this occurs, it may be necessary to discontinue treatment and discuss alternative methods of permanent reduction.
There is a slight possibility that if the skin blisters a permanent mark may be left on the skin. Test patches are used to avoid overdosing the area to the extent that they may produce those undesirable effects.

I am aware that I will need to have a test patch for each area that I intend on having treated.

I understand that if I fall pregnant, change medications, or start suffering from any medical conditions during my treatment course, I will need to inform my IPL clinician.

Consent: I hereby accept that the essential information necessary to make an informed decision has been given to me.

I have been fully informed of the risks that may be associated with IPL hair reduction as listed above and have had the opportunity to ask questions relating to the procedure I am about to undergo.

I have been given an information sheet and aftercare advice.

I understand that there are other treatment options available.

I also understand that adjustments to my treatment program may be necessary (including the possibility of having to discontinue my treatment program) if I experience Hyper/Hypo pigmentation, stimulated hair, or any other adverse side effects.

I have been provided with all the information on known possible side effects to enable me to make an informed choice on whether to commence with treatment.

I understand that the clinic cannot be held responsible for any unknown side effects which, although unlikely, may occur as a result of having IPL treatments.

I understand that no warranty or guarantee has been made to me as a result or cure. It is possible that results may not come up to expectations or goals.

The clinic will not be held financially liable provided treatments have been carried out in good faith.

Please sign your name.

Aspect™

Aspect DR™

Cosmedix