Laser Skin Resurfacing Consultation/Consent Form | Aesthetics Forms Portal

Laser Skin Resurfacing Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

Are you currently taking any medications (oral or topical)? *

Please list: *

Do you have any allergies? *

Please list: *

Do any of the following apply to you? Please tick all that apply.

Are you currently (or possibly may be) pregnant? *

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following have you been unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

What are your skin concerns? *

What are your goals and expectations of the treatment? *

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning

2) White skin, often with blue eyes - burns and does not tan easily

3) Fair skin with brown eyes and brown hair - burns first then tans

4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily

5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns

6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types best describes your skin? *

Do you have any tattoos? *

Please list location(s) and size(s): *

Tanning History (Direct sun, Self-tanners, Spray tans etc.). Please list and include last date of use: *

Have you previously had any laser treatment? *

Previous Laser Treatment(s) - If known, please specify date, number of treatments, frequency, response to treatment, device used: *

Do you use sunscreen? *

Do you smoke? *

Treatment Information

Laser resurfacing is one of the most advanced skin rejuvenation treatments available. It is hugely effective as a rejuvenation treatment which removes fine lines and wrinkles, tightens skin, evens out discolouration, repairs sun damage and smooths out rough skin. It can also treat deeper skin concerns such as scars, acne scars, hyper-pigmentation and pigmentation.

The laser creates beams of thermal energy which penetrate deep into the skin. The laser beams vaporise damaged skin and by stimulating your body’s natural healing process, encourage collagen production and cell regeneration to reveal glowing renewed skin.

If you have lines and wrinkles around your mouth, eyes or forehead and are looking for noticeable rejuvenation and younger-looking skin, this treatment will give you exceptional results. It can also treat skin conditions including scarring, acne scarring, hyper-pigmentation and pigmentation such as age spots and sunspots.

Areas of the face to be treated will be numbed with a local anesthetic. General anesthesia may be used when the entire face is treated. A partial-face laserabrasion takes 30 to 45 minutes, and the full-face treatment takes 1-1/2 to 2 hours. Your face or area to be treated will be thoroughly cleaned.

Treatment Preparation

Avoid tanning or heavy sun exposure and use a broad-spectrum sunscreen daily for 4 weeks before the treatment.
Avoid deep facial peel procedures for 4 weeks before treatment (i.e. strong chemical peels, laser resurfacing, dermabrasion).
Don’t use medications that cause photosensitivity (such as doxycycline, minocycline) for at least 72 hours prior to treatment.
If you have a history of herpes (oral cold sores, genital) or shingles in the treatment area, let your doctor know and start your antiviral medication (valacyclovir, acyclovir) as directed (usually two days before treatment and continue for 3 days after treatment).
To prepare your skin for laser resurfacing, you may be asked to apply a topical retinoid on your skin for about 4 weeks before your procedure.

Potential Side Effects

Milia, which are small, white bumps, may appear in the laser-treated areas during healing (up to a month after treatment). These may be removed by gentle cleansing with a washcloth.

Hyperpigmentation, and more rarely, hypopigmentation, may result in the laser-treated areas. You should use broad-spectrum sunscreens for weeks before and after the treatment to prevent pigmentary changes.

Reactivation of a herpes simplex cold sore may occur, especially after laser skin resurfacing around your mouth. You can prevent this by asking your doctor for an antiviral medication, which you can begin taking before your surgery and continue taking for 7 to 10 days after laser resurfacing.

You can also prevent bacterial infections by taking an antibiotic before the surgery and continuing to take it for 7 to 10 days afterwards.

You should expect swelling after laser skin resurfacing. Oral steroids can be prescribed to manage swelling around your eyes.

Scarring after laser skin resurfacing, although very rare, may occur in laser-treated areas.

Aftercare Advice

Following the laser procedure, the practitioner will bandage the treated areas. After 24 hours, you will need to clean the treated areas 4 to 5 times a day and then apply an ointment such as petroleum jelly to prevent scabs from forming.

You may feel itching or stinging for 12 to 72 hours after the procedure. 5 to 7 days after laser resurfacing, your skin will become dry and peel.

Depending on the problem that was treated, healing typically takes 10 to 21 days. Once the skin heals, you can wear oil-free makeup to minimize redness, which usually fades in 2 to 3 months.

You will also probably notice that your skin is lighter for a while after surgery. It is particularly important that you use a "broad-spectrum" sunscreen, which screens ultraviolet B and ultraviolet A rays, to protect your skin during that time. When selecting a sunscreen, look for one specially formulated for use on the face with a 7% (or higher) zinc oxide content and a sun protection factor (SPF) of 30 or higher. Limit your time in the sun, especially between the hours of 10 a.m. and 2 p.m., and wear protective clothing, such as long-sleeved shirts, pants, and a wide-brimmed hat. Reapply your sunscreen every 2 hours when you are out, and more often if you are sweating or swimming.

It is also important to keep your new skin well moisturized. If you use Retin A or glycolic acid products, you should be able to start using them again after about 6 weeks or when the practitioner says you can.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during, or immediately following, the treatment.

I fully understand the above and consent to the Laser Skin Resurfacing treatment(s) to be carried out.

Client Signature: *

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