Emergency Contact Name & Phone Number
Treatment Requested (please circle) Hair Removal / Skin Rejuvenation / Vascular / Pigmentation / Acne
Lifestyle & medical History – please tick or cross in the circle as appropriate. If you do not understand or recognise the condition then please discuss with your IPL operator.
Skin Pigmentation Disorders (e.g. melasma, vitiligo)
History of cancer (or chemo/radio therapy)
Currently taking any medication or any supplements?
No/Yes (please specify the condition & medications)
Currently using/used in the last 3 months, any of the following? (please circle)
St John’s Wort / Amiodarone / Tetracycline Antibiotics / Anticoagulants / Gold 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?
Ever had any of the following? (please circle)
Moles / Birthmarks / Tattoos / Permanent makeup / Chemical peel / Botox / Inject able fillers / None
Suffered from any skin disorder/disease? No / Yes
Had previous Laser or IPL treatment? No / Yes
Please indicate how your skin responds to midday summer sun exposure with no sunscreen:
Skin Type 2 Easily burnt, eventually gets a moderate tan
Skin Type 3 Sometimes burns, quickly gets an average tan
Skin Type 4 Rarely burns, quickly gets a deep tan
Skin Type 5 Very rarely burns, consistent tan
Do you currently have a real or fake tan? No / Yes
Have you had any sun exposure or sun beds in the last 4 weeks? No / Yes
What are your goals/expectations for the treatment?
Pre Treatment Check List To be completed by the therapist
(Tick to confirm points have been discussed)
How treatment works Pre/Post treatment care SPF Advice Typical no. of treatments/interval Likely clinical outcome Sensation during treatment Possible side effects Cost after sessions are finished
Informed Consent for IPL TreatmentPlease read this consent form and tick each box to indicate you understand and accept the information contained herein.
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 (for example in medications taken).
I understand that the results from this treatment vary considerably and a small percentage of people will not respond
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 there may be short-term side effects such as reddening, bruising, swelling, mild burning or blistering,
hypo-pigmentation, (lightening 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 there are certain risks associated with IPL and they include but are not limited to: redness, localised
swelling and mild tenderness. Although rare, adverse effects such as light burns, blister and bruises may occur. On occasion
IPL treatment may cause pigmentation changes to the skin.
I understand that I must wear protective eye goggles to prevent damage from the light.
I understand I must shave body parts for treatment 1 or 2 days before each session. I also understand that if areas are not
shaved, the salon is unable to continue with session and this will count as 1 session.
I understand no waxing, plucking in certain cases hair removal cream between treatments.
I understand any surcharges quoted for extended areas throughout my course of IPL. I have been quoted the following:
upper lip chin jaw line toes fingers underarms neck tummy line palm size of back of leg sides of bikini high bikini (surcharges) brazilian (surcharges) hollywood (surcharges) upper back upper chest shoulders forearms half leg (below knee) I certify that I have read and understood all the information and my questions have been answered
before signing this consent form. I consent to the terms of this agreement.
Treatment Assessment (to be completed by the operator)
I have been advised on how to care for my skin after the IPL treatment and I will follow the procedure as stated.
There have been no changes to my health history since my last treatment and I am not taking any new medication.
QVH NICE Technology Appraisal Report Report generated from local_bnf provided by FormularyComplete (www.pharmpress.com). Accessed 16 05 2013 updated 13 08 2013 Items/TAs marked as non-formulary are not relevant to the services provided by the Queen Victoria Hospital NHS Foundation Trust TA Number Medicine Title Formulary Status Comments Formulary for NICE indications as recommended
Level 4 Potential Conservation Area (PCA) Report Site Code IDENTIFIERS Site Class Site Alias Network of Conservation Areas (NCA) NCA Site ID NCA Site Code NCA Site Name Site Relations LOCATORS Latitude Longitude Quad Code Quad Name County Jefferson (CO) Watershed Code Watershed Name SITE DESCRIPTION Minimum Elevation 7,960.00 Feet M