IPL (Intense Pulsed Light) Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently, or possibly may be, pregnant? *

Do you have a history of active cold sores or herpes simplex virus? *

Have you taken Accutane (Isotretinoin) within the past year? *

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

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

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 would you say is closest to your skin? *

Which skin care products do you use? *

Have you ever had skin cancer? *

Have you used self-tanners or tan enhancers in the past 2 weeks? *

Please specify (including dates if possible): *

Do you use sunbeds or are regularly exposed to sun? *

What are your goals and expectations of the treatment? *

Treatment Information

What is Intense Pulsed Light (IPL) therapy?

Intense pulsed light (IPL) therapy, is a way to improve the color and texture of your skin without surgery. It can undo some of the visible damage caused by sun exposure -- called photoaging. You may notice it mostly on your face, neck, hands, or chest.

IPL may help if you have red, brown, or splotchy skin because of a health condition.

How IPL Treatment Works

IPL uses light energy to target a certain color in your skin.

When the skin is heated, your body gets rid of the unwanted cells, and that gets rid of the thing you’re being treated for. Unlike lasers, an IPL device sends out more than one wavelength of pulsating light. It can treat a range of skin conditions at the same time.

After IPL, you may look younger because your skin tone is more even. And since the light doesn’t hurt other tissue, you can get better quickly.

Effectiveness of IPL Treatment

How well IPL works can depend on what you want the treatment to fix.

Redness: After one to three treatments, light therapy can get rid of 50%-75% of broken blood vessels for most people. They could completely go away. While treated veins don’t come back, new ones might show up later.
- If rosacea causes your face to flush, IPL can be a good alternative to laser therapy. You may have better results if:
  - You’re under 40
  - Your condition is moderate to severe
Sun damage: You may see 70% less of the brown spots and redness caused by ultraviolet (UV) rays.
Hair removal: You’ll get the most benefit if you have light skin and dark hair. It may not work at all if you have dark skin or blonde hair.
Acne: IPL may help if you have acne or the scarring it causes. You may need about six sessions to notice a difference. Research is continuing.

Is it safe?

IPL is safe when done by a trained technician. But the treatment could cause hormonal brown spots to flare up. You could also have other unwanted side effects, for example.

Your skin could:

Scar
Hurt
Swell
Bleed
Become infected
Change color
Get crusty
Blister

Talk to your technician if you feel sick after your treatment or your symptoms get worse.

What to Expect During IPL Treatment

Before the procedure, don’t:

Tan in the sun, in a tanning bed, or with tanning creams for 4 weeks before you go
Wax, or get a chemical peel or collagen shots for 2 weeks before
Wear perfume, makeup, deodorant, or any skin irritants
Take aspirin or another drug that can make you bleed more
Take any medication that will make you sun-sensitive; for example, the antibiotic doxycycline.

Once you’re there, a technician will rub gel on your clean skin. You’ll wear dark glasses to protect your eyes. The handheld IPL device will go right on your body. The session will probably last 20 or 30 minutes. Large areas could take an hour or more.

While most people are fine with the light pulses, the treatment could sting a little. It might feel like someone is snapping a rubber band on you. Your technician can give you numbing cream to put on 30-60 minutes before treatment starts.

Aftercare Advice

It may feel like you have a sunburn for 4-6 hours after you’re finished. Ice packs or a cool washcloth can help relieve this pain.

Your skin may be red or bruised for a day or two. Some of your brown spots may get darker, but they should peel off within a few weeks.

While you heal:

Don’t apply makeup if your skin hurts.
Use moisturizing lotion.
Protect yourself with sunscreen. Make sure it has an SPF of at least 30 and a physical blocker like zinc. Reapply it every 2 hours, even if it’s not sunny outside.
Wash your face with cleanser for sensitive skin.

Your technician can tell you when it’s safe to return to your normal skin care routine. It might take a week.

Most people get between three and seven sessions. It depends on the condition you’re treating. You’ll wait 2-4 weeks between each visit. It may take several weeks for you to notice any changes in your skin.

Please tick the box to confirm: *

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

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and 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) and therefore I accept full liability/responsibility for the information given. 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 receive the Intense Pulsed Light (ILP) treatment

Client Signature: *

Tap or click on the signature above to sign