Lily's Beauty & Aesthetic || Laser / IPL Consultation Form

Emergency Contact Name & Number

Pregnant (or planning pregnancy)

PCOS/hormonal imbalance

Sun tanned/using sun beds or fake tan

Skin pigmentation disorders (e.g. melasma, vitiligo)

History of cancer (or chemo/radio therapy)

Herpes (shingles/cold sores)

Lymphatic/immune system disorders

History of keloid formation/scarring

Photosensitive conditions

Communicable diseases (hepatitis/HIV)

Are you currently taking any medication or any supplements? no / yes(please specify the condition & medications)

Oral or Topical Retinoids (e.g Roaccutane or Retin A)

Oral or Topical Steroids

Recovering from any major medical treatment or photodynamic therapy (PDT) within the last 6 months? No/Yes (please specify)

Tanning Injections or Enhancers

Skin disorder/disease?

Had previous Laser or IPL treatment?

What products do you use on your skin?

Do you currently have a real or fake tan?

How long ago was your last UV exposure?

Have you ever used tanning injections/enhancers/Melanotan?

What are your goals/expectations for the treatment?

Where did you hear about the clinic? Recommendation/Advert/Leaflet/Press/Other

Pre/Post treatment care

Light Soothe/Light Protect recommended

Typical no. of treatments/interval

Likely clinical outcome

Sensation during treatment

Possible side effects

Any further questions / comments

Previous/current treatments

Medication / Medical History?

Has the area had any recent UV exposure/lan/lake tan?

Do you Consent for your settings to be chnaged accordinngly to ensure clinical endpoints are met?

The information I have given is correct to the best of my knowledge, and I have not withheld any known medical state or condition. I will inform the IPL operator before treatment if there has been any change.
I understand that the results from this treatment vary considerably and a small percentage of people will not respond satisfactorily 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 on the treated area for the duration of the treatment (and for up to 1 month afterwards) or use a high sun protection factor to avoid sun damage. I understand that tanned skin cannot be treated.
I understand that there may be short-term side effects such as reddening, bruising, swelling, mild burning or blistering, hypo-pigmentation, fightening of the skin or hyper- pigmentation, (darkening of the skin), as well as rare side effects such as scarring and permanent discolouration.
I understand that I must wear protective eye goggles to prevent damage from the light.

Laser Operator Comments

Contact Info

Address: 49 High Street 20/21 Arndale Market Manchester United Kingdom M4 3AH
Mail: info@lilysbeautymcr.co.uk
Number: +44 7737 848993
Number: +44 161 834 5033
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Laser / IPL Consultation Form

Laser / IPL Consultation Form

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