• IPL Treatment Informed Consent

    Medical History
  • Date of Birth*
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  • IPL Treatment Informed Consent

    Medical History Page 2
  • The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered*
  • Pre and post care instructions have been discussed and are completely clear to me*
    • Flaking of pigmentated lesions - crust may take 5 to 10 days to disappear and it is important not to manipulate or pick which may otherwise lead to scarring
    • Discomfort - During the procedure, I might experience a sensation similar to a rubber band snap which degree will vary per my skin condition and area sensitivity but that does not last long.  A mild "Sun-Burn" sensation may follow for typicalluy up to one hours and will be reduced with application of cooling and soothing creams.
    • Reddening and swelling - severity and duration depend on the intensity of the treatment and the senisitiviy of the area to be treated.  The phenomena may be reduced with application of cooling and/or anti-inflammatory creams
    • Brusing may rarely occur and may last up to 2 weeks. 
    • Natural or artificial sun exposure in the past 3-4 weeks pre-op or the following 3-4 week post-op plan
    • Use of self–tanners or tan enhancer caps within the past 3-4 weeks pre-op plan
    • Photosensitive herbal preparations (St John’s Wort, Ginkgo Biloba, etc) or aromatherapy (essential oils)
    • Diseases which may be stimulated by light at 400 nm to 1200 nm, such as history of Systemic Lupus Erythematosus or Porphyria
    • Pregnant or possibility of pregnancy, postpartum or nursing

  • IPL Treatment Informed Consent

    Medical History Page 3
  • I consent to photographs being used for medical education or publication with applied discretion and not revealing my identity*
  • Click any that may Apply
  • Previous hair removal procedures on requested treatment area (other IPL/laser, wax, electrolysis, etc)*
  • Any observed modification (colour, size, texture and border) on the lesion to be treated?*
  • Any hair on requested treatment area that should not be removed?*
  • Previous skin procedures on requested treatment area (Botox, fillers, peels, etc..*

  • IPL Treatment Informed Consent

    Medical History Page 4
  • Intake of aspirin or anti-coagulants?*
  • Easy Bruising*
  • Any Known Allergies*

  • My signature certifies that I have duly read and understood the content of this informed consent form, and gave the accurate information as to my health condition. I hereby freely consent to M22 IPL skin treatments

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  • Date*
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