IPL Consultation Form

Please take a moment to fill out the form.

First Name

Last Name

Phone

Are you pregnant?

Yes

Are you breastfeeding?

Yes

Do you get regular cold sores?

Yes

Have you ever had skin cancer?

Yes

Have you ever had cancer?

Yes

Do you have any keloid scars?

Yes

Have you ever taken Roaccutane?

Yes

If yes, how long ago?

Have you ever taken St Johns Wart?

Yes

If yes, how long ago?

Do you suffer with Polycystic Ovarian Syndrome?

Yes

Do you have any allergies?

Do you have any thyroid conditions?

Yes

Have you had any past major / minor operations?

Yes

Do you have a pacemaker?

Yes

Do you have diabetes?

Yes

Do you have any form of epilepsy?

Yes

Do you have any immune deficiencies? Lupus?

Yes

Do you use Retin A or Retinol?

Yes

Do you have any warts, verrucae or nail fungal infections?

Yes

When was your last sun exposure?

Are you a smoker?

Yes

Please indicate how your skin responds to midday summer sun exposure with no sunscreen:

Please list any medications, herbal remedies and birth control you are currently taking:

Current and previous medical conditions:

Notes relating to questionnaire:

How did you hear about us?

How to prepare for the treatment:

It is important to avoid the following within a 30 - 60 days period prior to treatment:
• Do NOT sunbathe or use sun beds
• Avoid self-tanning products

For 7 days prior to the treatment:
• Do NOT have electrolysis, Do NOT wax
• Do NOT bleach, Do NOT use depilatory creams
• Do NOT use anti-inflammatory medications (including aspirin & ibuprofen)

NOTE: Please refrain from smoking 4 hours before treatment.

Before hair removal session, hair have to be shaved completely, however a small patch must remain for hair type assesment.

Informed consent - skin rejuvenation / acne treatment / rosacea / pokiloderma

Intense Pulsed Light treatment is a method of treating sun-damaged skin. Over exposure to UV light can cause mottled/uneven pigmentation, open pores, sunspots, rosacea, poikiloderma of Civatteand diffuse redness. Treatments using the Ellipse System will not cure any medical conditions causing pigmentation or diffuse redness.

The purpose of the treatment is to achieve improvements in the appearance of the skin by improving skin colour, tone and pore size using Intense Pulsed Light to target excess pigmentation and diffuse redness.

I hereby authorise MADA Clinic and Spa to treat me using the Ellipse system for Skin Rejuvenation. I understand that the removal of all pigmentation and diffuse redness will not be 100 % and that multiple treatments may be necessary to achieve the best results.

MADA Clinic and Spa has informed me about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have.

I understand that there are certain risks associated with Intense Pulsed Light treatment and they include but are not limited to the following:

Post treatment discomfort like localised swelling, redness and mild tenderness.
Although uncommon the intense pulsed light treatment may cause blisters, light burns or bruises to the surface of the skin.
Transient hypo or hyper pigmentation may occur and will normally fade in 3 to 6 months.
Crust formation “dirt skin” look is commonly seen for up to 10 days after treatment

Informed consent - facial thread veins

Intense Pulsed Light treatment is a method of treating Facial Thread veins. Over exposure to UV light, extreme weather conditions, some medical conditions and trauma can cause damaged blood vessels. Treatments using the Ellipse System will not cure any medical conditions causing thread veins.

The purpose of the treatment is to achieve improvements in the appearance of the skin by using Intense Pulsed Light to reduce and remove thread veins.

I hereby authorise MADA Clinic and Spa to treat me using the Ellipse system for Facial Thread Veins. I understand that the removal of thread veins will not be 100 %, that return of some vessels is possible and that multiple treatments will be necessary to achieve the best results.

MADA Clinic and Spa has informed me about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have.

I understand that there are certain risks associated with Intense Pulsed Light treatment and they include but are not limited to the following:

Post treatment discomfort like localised swelling, redness and mild tenderness
Commonly the treatment will cause swelling to the area, which can last for up to 4 days
Although uncommon the intense pulsed light treatment may cause blisters, light burns or bruises
Rarely temporary hypo or hyper pigmentation may occur and will normally fade in 3 to 6 months.

Informed consent - hair removal

Intense Pulsed Light treatment is a method of treating unwanted hair. Unwanted hair may be caused by medical conditions such as hirsuitism, hypertrichosis and other disorders. Treatments using the Ellipse System will not cure any medical conditions causing unwanted hair.

The purpose of the treatment is to achieve cosmetic improvements reducing hair growth by using Intense Pulsed Light to destroy hair follicles.

I hereby authorise MADA Clinic and Spa to treat me using the Ellipse system for the reduction of my unwanted hair. I understand that the reduction of unwanted hair will not be 100 % and that multiple treatments are necessary based on the unique growth cycle of hair. I also understand that the treatment of unwanted hair using Intense Pulsed Light may need to be performed in repeated sessions in the future to obtain optimal results.

MADA Clinic and Spa have informed me about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have.

I understand that there are certain risks associated with Intense Pulsed Light treatment 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 temporary pigmentation changes to the skin.

I agree to follow the post treatment recommendations advised by MADA Clinic and Spa in order to ensure the best possible results. I understand that

swimming, gym and excessive heat should be avoided for 48 hours
exposure to the sun, sunbed and fake tan must be avoided for 30-60 days before treatment and 30-60 days after treatment.
a sun block of SPF 30+ must be used on the exposed skin areas. Otherwise it is possible that blotchy skin pigmentation, hyper- or hypo-pigmentation might occur.

I agree to co-operate with the recommendations of MADA Clinic and Spa while I am under their care, realising that any lack of co-operation could result in less than optimum results. I also agree to inform the clinic above immediately should any adverse effects occur.

I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure.

I agree to pay for the above mentioned services and understand that there will be no refunds for any performed services.

I hereby authorize MADA Clinic and Spa to use my photo and/or information related to my experiences with my treatment with associated devices and products. I understand this information may be used in publications, presentations, promotional literature, advertising, social media and/or other similar ways.

Date of signing

Your Signature

Thanks for submitting!