Consent Form

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E-LUX Consultation & Consent Form

Rejuvenates and tightens your skin using advanced E-LUX technology to deliver a smoother, firmer, more youthful glow, book your treatment today!

Title

Mr. Mrs Miss Ms

Name:

Date:

Adderss:

Phone:

E-mail:

DOB:

Emergency Contact:

Please list all medications that you take regularly, including hormones, vitamins, etc.:

Areas of concern:

How often?

Is there a family history of superfluous (excess) hair?

Yes No

Details:

Allergies:

Are you currently under doctors’ care?

Yes No

Details

Do you smoke?

Yes No

If so, how many per day?

Are you on HRT? (Hormone replacement therapy)

Yes No

Have you had (in area of treatment):

Chemical Peel Dermabrasion Laser Surgery

Other

Do you have permanent makeup/implants or injectables (Filler/Botox) in treatment area?

Yes No

Details:

Have got ANY type of skin tan (fake or natural/sun exposure)?

Yes No

Details:

How did you hear about us?

Skin Type Analysis

How would you rate your skin in the area to be treated?

Type 1: Always burn, never tan. Extremely fair skin/blonde hair/blue/green eyes. Type 2: Usually burn, tan less than about average. Fair skin, sandy brown to brown hair, green/blue eyes. Type 3: Sometimes burns, gradually tans about average. Medium skin, brown hair, green/brown eyes. Type 4: Sometimes burns, tans light brown or olive skin, dark brown eyes and hair. Type 5: Rarely burns, tans profusely. Dark brown skin, black hair, black eyes Type 6: Deeply pigmented, never burns. Black skin, black hair, black eyes

Test Patch

Date

Area

J/cm

Mode

Notes/ Results

Client Treament Report

Date of Treatment

Clinician Name

Clinician Signature

Treatment Details

Wavelength

J/cm2

Amount Paid

Clinician Signature

Medical Informed Consent

I consent and authorise________________________________ to perform laser light treatment on me. I understand the following points and have had the opportunity to ask questions during my consultation

In relation to my initial and all subsequent treatments I advise that: (Please tick)

Treatment is successful on most clients but my individual results cannot be guaranteed.
Most clients will require 4 treatments for successful reduction of pigmentation/capillaries and results are variable.
Darker pigmentation responds better to treatment than lighter pigmentation, and micro-crusting will occur.
Exposure to UV Rays will cause pigmentation to darken again, skin care is essential.
Vascular lesions may re-appear within 7 days after treatment, whilst the capillary is still compromised, a further treatment is highly recommended within 14 days, failure to do so, will reduce efficacy of treatment.

In relation to laser photo-rejuvenation treatments, I have been advised as follows:

Treatment is successful on most clients but my individual results cannot be guaranteed.
Most clients require 8 – 10 treatments to achieve up to 80% hair reduction, some may require more. Hair loss is variable and individual results depend on many factors, thus it is extremely difficult to advise on exact number of treatments required.
Blonde and red hair will have some reduction, however not same as black hair, no guarantee for grey hair.
Fine facial hair takes longer to respond to treatment than hair in other areas and will require additional treatments.
Darker skin type clients will require additional treatments.
Exposure to UV Rays will compromise my treatment, therefore I will use SPF 30+ sunscreen.
Growth of dormant follicles that may be triggered by hormonal changes (e.g. stress, illness, medications, pregnancy, trauma or other causes) can stimulate future hair growth.
Not following the program regarding timing of treatments will reduce efficacy of my treatment.

Risks associated with laser treatments (hair removal and photo-rejuvenation) Even though the risk of complication is extremely low, the following can occur: (Please tick)

Pigment changes (light or dark spots on the skin) lasting 1 – 6 months. Freckles may temporarily or permanently disappear in treated areas. Allergic or delayed inflammatory reactions can develop. A test patch is performed to ascertain reaction of the skin to IPL/laser. Laser light systems can cause eye injury and protective eyewear must be worn during treatment. Prior to initiation of treatment, any pigmented lesions should be correctly identified by a physician to be benign and recommended for light-based treatment. A medical certificate to this effect is required. I consent to photographs taken to evaluate effectiveness. Photographs revealing my identity will not be used without consent. I understand the sensation of light-based treatments is sometimes uncomfortable and feels like a flicking sensation. I am aged 18 years or over (otherwise parent or guardian to sign). I will advise (salon) of any changes that occur during my treatment that can increase potential risks or reduce efficacy. I also understand that there will be no refund for any performed services.

In relation to my initial and all subsequent treatments I advise that: (Please tick)

I have read all of the above and had all my questions satisfactorily answered.
Note: Do not sign this form until you have read and understood all of the above.

Client Full Name(Please print name)

Client Signature

Date

Parent/Guardian Full Name (Please print name) *Under 18 years of age requires parental consent

Parent/Guardian Signature

Date

Consent Form

Schedule Your Visit Today

E-LUX Consultation & Consent Form

Test Patch

Client Treament Report

Medical Informed Consent

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