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Home
About
About
Brands
Treatments
Skin Treatments
Results
Before and Afters
Brides
Blog
Explore Blogs
Shop
Shop All Products
Treatments & Vouchers
Book
Contact
Contact
Consultation Form
Skin needling Consultation Form
IPL Consultation Form
Client Feedback
FAQ
IPL Consultation Form
Full Name
*
First Name
Last Name
Address
Post Code
*
D.O.B
*
Phone
*
Email
*
How did you find out about SJM Skin Aesthetics?
Are you happy for us to share your before and afters on social media?
*
Yes
No
Ethic Origin?
*
Occupation?
Treatment requested?
*
Vascular
Pigmentation
Rejuvenation
Acne
Areas to be treated
Full Face
Nose/Cheeks
Half Face
Skin Spot
Full Face, Neck and Décolletage
Nose
Chest
Hands
Neck
Cheeks
Please select any of the following if applicable to you
*
Pregnant or planning
Skin Pigmentation Disorders (Melasma, Vitiligo)
Diabetes
Lymphatic/Immune Disorders
Lupus
Depression/Anxiety
High Blood Pressure
Sun tanned/Solarium/Fake Tan
History of Cancer (Chemo/Radio Therapy)
Epilepsy
History of Keloid formation/scarring
Hepatitis/HIV
Thyroid Condition
Psoriasis/Eczema/Allergies
Herpes (Shingles/Cold Sores
Photosensitive Conditions
Have you used any of the following oral/topical medications in the past 3 months?
*
St Johns Wort
Antibiotics
Roaccutane
Oral/Topical Steroids
No, none of the above
Are you recovering from any major medical treatments within the past 3 months? If YES, please specify
*
Have you had IPL treatment or laser treatment before?
*
What products do you use on your skin?
Do you currently have fake tan or an active tan fro the sun within 2 weeks old?
*
YES
NO
Informed Consent for IPL Treatment
*
The information I have given is correct to my knowledge and I have not withheld any medical state or condition. I will inform that the IPL operator before treatment if there has been any change. I understand that the results from this treatment vary considerably and small percentage of people will not respond satisfactory to treatment. I understand multiple treatments are necessary to achieve satisfactory results. I understand there is no guarantee of permanent results and maintenance treatments may be necessary. I understand that I must avoid sun exposure and fake tan on the treated area for the duration of the treatment (and for up to 3 weeks afterwards) or use high sun protection factor to avoid sun damage. I understand that there may be short term side effects such as reddening, bruising, swelling, mild burning or blistering, hyperpigmentation (darkening of the skin), hypo pigmentation (lightening of the skin), as well as rare side effects such as scarring and permanent discolouration. I understand that there are certain risks associated with IPL and they include but are not limited to redness, localised swelling and mild tenderness. Although rare, adverse affects such as light burns, blisters and bruisers may occur. On occasion, IPL treatment may cause pigmentation changes to the skin. I understand that I must wear protective eye wear to prevent damage from the light. I understand no waxing or plucking on the area is to be done 3 weeks before treatment. I understand there have been no guarantees made to me and results of hair removal are not 100% permanent. I acknowledge to follow my IPL clinicians advice pre and post care
PLEASE TICK BOX TO INDICATE YOU UNDERSTAND AND ACCEPT THE INFORMATION CONTAINED
Thank you, your consultation form has been received.
SJM Skin Aesthetics