LASER TREATMENT CONSULTATION FORM USING LASER DIODE/ND-YAG/IPL

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Todays Date (required)

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Your Name and Surname (required)

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Your Email (required)

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Mobile Number (required)

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Telephone

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Your Address (required)

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Your DOB (required)

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Your Sex? (required)

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Which treatment & areas are you interested in having, And/or have you been treated in the past?

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Treatment Type (required)

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Area to be Treated (required)

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Has this area been treated in the past? (required)

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Did you experience any reaction? (required)

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How often do you sunbathe? (required)

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When you sunbathe, how does your skin respond? (required)

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Has this area been treated in the past? (required)

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Have you used any of the following in the past 30-60 days?

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Sunbeds (required)

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Self Tanning Cream(required)

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Tanning in the Sun(required)

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When was your most recent holiday in the Sun?(required)

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When are you planning your next Sun holiday?(required)

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[uacf7_step_start uacf7_step_start-801 "Medical History"]

Do any of the following apply to you? Please Tick any that apply.

Heart DiseasePacemakerBurns /skin graftLiver /Kidney diseasePort wine stainHaemangiomaPolycystic ovarian syndromeSteroid of Hormonal therapyThyroid hormone deficiencyHormonal ImbalancesGold injectionsCancer (radiation/chemotherapy)Herpes (or cold sores)Keloid formations / ScarsMelanoma / MolesLupus DiseaseActive Tan (30 days)Skin PigmentationClotting disordersAnti-inflammatory medicationHirsutismAcneShinglesDiabetesAidsVitiligoPsoriasisEpilepsyHaemophiliaAnti-coagulants

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Are you currently being treated for a any medical condition?

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If Yes Please Specify

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Have you ever had any laser treatments in the last 6 months?

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If Yes Please Specify

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Have you ever used (or currently using) Retin A or Glycolic Acid?

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If Yes Please Specify

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Have you ever used or are you currently using Roaccutane?

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If Yes Please Specify

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Have you ever had a chemical peel?

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If Yes Please Specify

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Are you currently taking medication?

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If Yes Please Specify

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Do you have any implants?

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If Yes Please Specify

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Any tattoos or permanent make-up?

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If Yes Please Specify

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Have you ever been treated by an endocrinologist?

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If Yes Please Specify

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Do you have any particular skin sensitivities or allergies?

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If Yes Please Specify

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Have you had any major surgery performed in the last 3 months?

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If Yes Please Specify

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Have you read and understood all the information given to you in your Treatment Information Package, including all contra-indications?

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[uacf7_step_start uacf7_step_start-802 "Informed Consent"]

Intense Pulsed Light, Laser Diode and Nd-Yag are types of laser used to treat matters of the skin. Some matters may be caused by medical conditions, treatments using the All White 3 V Combo Plus will not cure any medical conditions.
The purpose of the treatment is to achieve cosmetic improvements by using Laser Diode/Intense Pulsed Light/NdYag Laser.

The Areas to be treated are:

I hereby authorise Sunnyside Skin Clinic to treat me using the All White 3 V Combo Plus. I understand that the results may not be 100 % and that multiple treatments may be necessary to achieve optimal results.
Sunnyside Skin Clinic have informed me about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have.
I understand that there are certain risks associated with Laser Diode/Nd-Yag/Intense Pulsed Light laser treatment and they include but are not limited to:
• Redness, localised swelling and mild tenderness which may last up to 4 days
• Although rare, adverse effects such as light burns, blister and bruises may occur.
• Crust formation or scabbing may occur
• Rarely treatment may cause transient hypo or hyper pigmentation changes to the skin which normally fade in 3-6 months
I agree to follow the post treatment recommendations advised by Sunnyside Skin Clinic in order to ensure the best possible results. I understand that excessive heat should be avoided for 48 hours and that exposure to the sun including sunbed and fake tan must be avoided for 30 days before treatment and 30 days after treatment, also a sun block of SPF 30+ must be used on the exposed skin areas. Otherwise it is possible that blotchy skin pigmentation, hyper- or hypo-pigmentation might occur.
I agree to co-operate with the recommendations of Sunnyside Skin Clinic while I am under their care, realising that any lack of
co-operation could result in less than optimum results.
I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction.
I fully understand the treatment conditions and procedure.

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