IPL Skin Rejuvenation Consultation Form
Surname: _______________________
First Name: _____________________
Today’s Date: ____/____/_____
Photograph Ref ___________________________
Photographs taken date ____________________
Treatment Status Checklist
Please tick & date where appropriate:
Consent signed
Date_______
Course Client
Date_______
Single Payment Client
Date_______
Deposit has been paid
Date_______
Paid in full
Date_______
Aftercare sheets given
Date_______
Notes
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PERSONAL INFORMATION
Surname __________________________ First Name ______________________
Address ___________________________________________________________
Postcode ______________
Date of Birth ____/___/_____
Tel No: __________________________
Gender: M / F
Mobile Number ____________________ Email ____________________________
Profession: ___________________________________________________________________
How did you hear about us ______________________________________________________
Expectations and Motivations
_____________________________________________________________________________
Please tick if you would not like to receive our special offers
Child(ren) and Age(s)
____________________________________________________________________________
Personal Medical History (Current Complaint)
What type of problem are you consulting for:
Sun spots
Wrinkles
Distended blood vessels (red spots that may be spidery in appearance)
Flushing of the skin
Large pores
How many years have you noticed this problem?
At what age did this skin problem occur?
Are your present skin problems getting more pronounced?
Yes
No
Have you received prior treatment for this problem?
If yes, when?
By what method?
Yes
No
Are you currently taking medication for your skin problem?
Yes
No
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If yes, which medication?
When where you last exposed to the sun (including tanning
booth)?
Do you use chemical sun tanning lotions?
Yes
No
Are you planning a holiday in the sun?
Yes
No
Fitzpatrick Wrinkle Class _______
Class
Wrinkling
I
Fine wrinkles
II
Fine to moderate depth wrinkles, moderate number of lines
III
Fine to deep wrinkles, numerous lines, with our without redundant skin folds
Fitzpatrick Elastosis Score _______
Score
Degree of Elastosis
1–3
Mild (fine textural changes with subtly accentuated skin lines)
Moderate (distinct papular elastosis, individual papules with yellow
4–6
translucency under direct lighting, and dyschromia)
Severe (multipapular and confluent clastosis (thickened yellow and pallid)
7–9
approaching or consistent with cutis rhomboidalis)
Mark your skin type (when exposed to the sun without protection for about 1 hour):
I
II
III
IV
V
VI
Always burns, never tans
Always burns, sometimes tans
Sometimes burns, sometimes tans
Always tans
Hispanic, Asian, Mediterranean, Middle Eastern
Black
Skin Care Regimen (explain in detail type of products)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Date completed ______________________ Signed ____________________
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Medical Assessment
Are you taking any medication ________________________________________________________
Do you have any allergies ____________________________________________________________
Pregnancy (previous and current) ____________________________________________________
Are you currently receiving medical treatment __________________________________________
Have you had any recent operations/scar tissue:_________________________________________
Do you have any tumors, abnormal swelling or lymph oedema _____________________________
Do you have any heart/cardiac disorders _______________________________________________
Do you suffer from Herpes Simplex 2 (cold sores) ________________________________________
Have you recently had Botox/Collagen/injectables _______________________________________
Do you take any form of contraception/hormonal substitutive ______________________________
Do you have a tattoo/semi permanent make up in the area __________________________________
Do you have Thrombosis/Phlebitis (blood clots) __________________________________________
Do you have a Pacemaker or internal metal pins _________________________________________
Is there a personal/family history of skin cancer _________________________________________
Do you have epilepsy _______________________________________________________________
Surgeries _________________________________________________________________________
Do you have any of the following: Thyroid problem ________________________________________
Are you taking any herbal preparations? (St. John's Wort)
Yes
Date completed ______________________ Signed ____________________
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No
Informed Consent
I understand that the IPL System is intended for Photorejuvenation, benign vascular and pigmented
lesions, and/or permanent hair reduction and that clinical result may vary in different skin types. I
understand that there is a possibility of rare side effects such as scarring and permanent
discoloration as well as short-term effects such as reddening, mild burning, temporary bruising and
temporary discoloration of the skin.
These effects have all been fully explained to me _______ (please initial).
Based on the experience of many other physicians we have found that those people who tend to
sunburn rather than tan, usually obtain good results on the first and subsequent visits. On the other
hand, those who tan more easily tend to have more variation in their results. Some patients in this
category will experience partial results and some will experience no improvement at all.
I understand that the treatment by the IPL system involves payment, and the fee structure has been
fully explained to me.
I also understand that there are other options for treatment available and each of these other
options were fully explained to me __________ (please initial).
With this in mind, I am choosing to try IPL non-invasive treatment for Photorejuvenation, vascular,
pigmented lesions and/or permanent hair reduction.
Photographs
I do ____ do not ___ give permission for photographs and other audio-visual and graphic materials
to be used by the physician for marketing, education-promotion purposes. Although the
photographs or accompanying material will not contain my name or any other identifying
information, I am aware that I may or may not be identified by the photos.
Signature _____________________________________________
I read and understand this agreement. My questions were answered to my satisfaction. I agree to
the terms of this agreement.
Patient’s Name:
Signature:
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Consultation Record
Date ________________________________________________________
Practitioner ___________________________________________________
Medical Questionnaire completed and checked ______________________
Consent signed ________________________________________________
Pre and Post instructions given ___________________________________
Photographs taken ___________________________________________
Payment advised and agreed ___________________________________
Test patch date _______________________________________________
Notes
__________________________________________________________________________________
__________________________________________________________________________________
Payment Details
Course Payment Plan
Single Payment Plan
Single Payment
Date
Initialed
Course Payment
Date
Amt Trts
I agree to the above type of payment plan Option
A Single Payment B Course Payment
A The amount I agree to pay per Treatment is ______________ Date __________
B The amount I agree to pay for a Course of Treatment is _________Date _______
Signature of Patient __________________________ Date ____________________
Signature of Operator _________________________Date ____________________
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Initialed
Patient Name _________________________________
Date
Treatment Notes
MODE
FILTER
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Time
FLUENCE
# OF PULSES
PULSE DURATION
Practitioner
PULSE DELAY
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Adverse Events Record
Description
Severity
Relation to
Procedure
Action Taken
Outcome
Signs of infection
Severe, unremitting pain
Erythema
Hyperpigmentation
Hypopigmentation
Persistent purpura
Burns and/or blisters
Scarring
Other
Mild
Moderate
Severe
Probable
Possible
No relationship
None
Discontinued treatment
temporarily
Discontinued treatment
permanently
Remedial treatment,
specify below
Recovered
Improved
Unchanged
Worsened
Insufficient
follow-up
Definitions
Adverse Events
Fill in the date and the appropriate numbers as described in the table above.
#
Date
1
2
3
4
5
6
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Description
Severity
Relation to
Procedure
Action Taken
Outcome
Treatment Record
Please sign the section below each time a treatment is carried out to ensure no changes.
Statement
I agree that I have not changed any medications/taken additional medications prior to this
treatment
I have not been exposed (in the area to be treated) to the sun or sunbeds for prolonged periods
without suitable protection.
I have not used any tanning or colouring products on my skin in the last two weeks
I have not bleached, plucked or removed hair with depilatory cream.
I have not used any harsh chemicals/peels in the area to be treated (e.g. Retinol)
DATE
Name and patient No
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Signed
Therapist
Prescriptive sheet
Prescribed by:__________________
Morning
Cleanse and purify:
______________________________
Moisturise and protect:
______________________________
D = Dry
Dh = Dehydrated
O = Oily
DL = Deep lines
S = Sensitivity
P = Pigmentation
B = Breakouts
C = comedones
Evening
Cleanse and purify:
______________________________
Youth promoting:
______________________________
Moisturise and protect:
______________________________
Advice / Additional prescription
_______________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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Pre and Post treatment – Vascular and pigmentation
Before the treatment

Avoid the sun, sun beds and do not apply tanning preparations to the area.

Please advise us if there have been any changes to your health or medications?

Wear something that will not cause friction in the area to be treated after the treatment.

Do not use any harsh products on the skin 48hours prior to treatment – Glycolic or acid
based products)

Do not use Retinol based products prior to treatment
During the treatment

You will be asked to wear special goggles to protect your eyes.

The skin will be cleaned.

The IPL will produce a reddening effect on the skin and a darkening effect on the pigment,
these will fade/flake off in days

Cooling may be applied after the treatment whilst the skin feels hot
After the treatment

Keep the treated area clean and dry.

Apply a high factor 30+ skin protection every day.

If there is any discomfort iced water or a cool clean cloth will sooth the area

Make sure clothes are not rubbing the treated area

Do not expose the treated area to heat such as hot baths etc

Swimming should be avoided until the area is fully healed.

Do not scratch the skin treated, if scabs form these must not be picked, or secondary
infection is possible.

Do not expose the treated area to the sun or sunbeds.
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