IPL Form CLIENT INFORMATION & MEDICAL HISTORY In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential. Step 1 of 2 50% PERSONAL HISTORY First Name Last Name Date of Birth MM slash DD slash YYYY AgeOccupation Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Name Emergency Contact PhoneWhich of the following best describes your skin type? Always burns, never tans Always burns, sometimes tans Sometimes burns, always tans Rarely burns, always tans Brown, moderately pigmented skin Black skin MEDICAL HISTORYAre you currently under the care of a physician? Yes No If yes, for what: Are you currently under the care of a dermatologist? Yes No If yes, for what: Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation? Yes No Do you have any of the following medical conditions? (Please check all that apply) Cancer Diabetes High blood pressure Herpes Frequent cold sores HIV/AIDS Keloid Scarring Skin disease/Skin lesions Seizure disorder Hepatitis Hormone imbalance Thyroid imbalance Blood clotting abnormalities Any active infection Do you have any other health problems or medical conditions? Please list: Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced) Food Latex Aspirin Lidocaine Hydroquinone or skin bleaching agents Others Please describe Do you have any specific skin problems pertaining to your body? Yes No If YES, specify: Check all skincare products you are currently using: Soap Toner Masque Cleanser Moisturizer Scrub/Peel Other (specify) Other (specify) MEDICATIONSWhat oral medications are you presently taking? Birth control pills Hormones Others (Please list) Other (specify) Are you on any mood altering or anti-depression medication? Have you ever used Accutane? Yes No If yes, when did you last use it? What topical medications or creams are you currently using? Retin-A Others (Please list): What herbal supplements do you use regularly? HISTORYHave you ever had laser hair removal? Yes No Have you used any of the following hair removal methods in the past six weeks? Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories Have you had any recent tanning or sun exposure that changed the color of your skin? Yes No Have you recently used any self-tanning lotions or treatments? Yes No Do you form thick or raised scars from cuts or burns? Yes No Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? Yes No If yes: FEMALE CLIENTS ONLYAre you pregnant or trying to become pregnant? Yes No Are you breastfeeding? Yes No Are you using contraception? Yes No SignatureMy signature below indicates, to the best of my knowledge, the information I have provided is correct and complete, and I have not withheld any information that may be relevant to my treatment. Date Signed MM slash DD slash YYYY INFORMED CONSENT FOR REMOVAL/REDUCTION ROSACEA & SPIDER VEINSName Date MM slash DD slash YYYY I authorize to perform the procedure. The light pulsed system may dramatically reduce darkly pigmented sunspots and spider veins. More than one laser session may be necessary to achieve desired results. However, other treatments, including skin care products, are often needed to blend color, reduce sun damage, and give the best results. The FDA has given the clearance for removal of brown spots, spider veins, and rosacea. The skin treated will be red and swollen with fine, thin scabs forming. Keep the treated areas covered with Polysporin and Aquaphor until the thin scabs fall off. This process will take anywhere from 1-3 weeks. It could take as long as 3-6 months in some rare cases. Do Not scratch the scabs, as that can cause scarring. We are unable to treat clients that are on ACCUTANE and PHOTOSENSITIZING medications. Clients using ANTICOAGULANTS should be noted. The following problems may occur with treatment. Scarring: The light pulsed system can create a bruising and a moderate burn or blister to the skin. For an effective treatment, the power (joules) needs to be below the blistering point which means the skin will be red. There is a risk of scarring. Hyper-pigmentation (browning) and Hypo-pigmentation (whitening) have been noted after treatment, especially with a darker complexion. This usually resolves within weeks, but it can take as long as 3-6 months in some cases. Permanent color change is a rare risk. If you have a lot of color in your skin, a skin lightening cream will be advised to reduce the melanin in your skin before the treatment. Avoiding sun exposure after the treatment is crucial to reduce the risk of color change. Infection: Although infection following pulsed light treatment is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a laser treatment. This applies to both individuals with a past history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatment including antibiotics might be necessary. If you have a history of herpes simplex virus in the treated area we recommend preventative therapy. Bleeding: Pinpoint bleeding is rare but can occur following brown spot and spider vein treatment procedures. Should bleeding occur, additional treatment might be necessary. Skin Tissue Pathology: Energy directed at skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible. Only clearly benign pigmented lesions can be treated. Check with your doctor for clearance for the treatment. Allergic reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations, have been reported. Systematic reactions (which are more serious) may result from prescription medication. Allergic reactions may require additional treatment. Wear sunscreen of SPF 25 or higher before and after treatment to protect your skin. I understand that exposure of my eyes to light could harm my vision. I will keep the eye protection on at all times. I understand that I may need multiple treatments for the desired outcome. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, hyperpigmentation, and hypo-pigmentation. Occasionally, unforeseen mechanical problems may occur and your appointment may need to be rescheduled. We will make every effort to notify you prior to the arrival in the facility. Please be understanding if we cause you any inconvenience. AKNOWLEDGEMENT: My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release (Individual) and Amenity Day Spa (Facility) and Dr. Lee (Doctor) from all liabilities associated with the above indicated procedure. Client/Guardian Signature:We are unable to treat clients that are on ACCUTANE and PHOTOSENSITIZING medications. Clients using ANTICOAGULANTS should be noted. The following problems may occur with treatment. Scarring: The light pulsed system can create a bruising and a moderate burn or blister to the skin. For an effective treatment, the power (joules) needs to be below the blistering point which means the skin will be red. There is a risk of scarring. Hyper-pigmentation (browning) and Hypo-pigmentation (whitening) have been noted after treatment, especially with a darker complexion. This usually resolves within weeks, but it can take as long as 3-6 months in some cases. Permanent color change is a rare risk. If you have a lot of color in your skin, a skin lightening cream will be advised to reduce the melanin in your skin before the treatment. Avoiding sun exposure after the treatment is crucial to reduce the risk of color change. Infection: Although infection following pulsed light treatment is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a laser treatment. This applies to both individuals with a past history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatment including antibiotics might be necessary. If you have a history of herpes simplex virus in the treated area we recommend preventative therapy. Bleeding: Pinpoint bleeding is rare but can occur following brown spot and spider vein treatment procedures. Should bleeding occur, additional treatment might be necessary. Skin Tissue Pathology: Energy directed at skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible. Only clearly benign pigmented lesions can be treated. Check with your doctor for clearance for the treatment. Allergic reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations, have been reported. Systematic reactions (which are more serious) may result from prescription medication. Allergic reactions may require additional treatment. Wear sunscreen of SPF 25 or higher before and after treatment to protect your skin. I understand that exposure of my eyes to light could harm my vision. I will keep the eye protection on at all times. I understand that I may need multiple treatments for the desired outcome. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, hyperpigmentation, and hypo-pigmentation. Occasionally, unforeseen mechanical problems may occur and your appointment may need to be rescheduled. We will make every effort to notify you prior to the arrival in the facility. Please be understanding if we cause you any inconvenience. AKNOWLEDGEMENT: Date MM slash DD slash YYYY Laser Technician Signature:Date MM slash DD slash YYYY CAPTCHA
