IPL Skin Rejuvenation Consultation Form

Please complete all sections so we can better understand your skin and medical history.

Personal

Complaint

Skin Type

Regimen

Medical

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Personal Information

Basic contact details.

Surname

First Name

Address

Postcode

Tel No

Date of Birth

Gender

M F

Mobile Number

Profession

How did you hear about us

Expectations and Motivations

Child(ren) and Age(s)

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Skin Type

Mark your skin type (when exposed to the sun without protection for about 1 hour).

IAlways burns, never tans IIAlways burns, sometimes tans IIISometimes burns, sometimes tans IVAlways tans VHispanic, Asian, Mediterranean, Middle Eastern VIBlack

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Skin Care Regimen

Explain in detail the type of products you currently use.

Skin Care Regimen

Date completed

Signed

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Medical Assessment

This information helps us ensure your treatment is safe.

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 No

Date completed

Signed

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Apply for a Consultation

Booking Form

IPL Skin Rejuvenation Consultation Form

Personal Information

Personal Medical History — Current Complaint

Skin Type

Skin Care Regimen

Medical Assessment

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