Chemical Peels Dermafrac And Dermapen Treatments Personal History

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Personal History For Chemical Peels Dermafrac And Dermapen Treatments

Title

First Name(Required)

Last Name(Required)

Sex

Male

Female

Date of Birth

DD slash MM slash YYYY

Address

Suburb

Post Code

Mobile Number(Required)

Email(Required)

State(Required)

NSW Clinics(Required)

ACT Clinics(Required)

Would you like to receive marketing materials for promos or sales?

Emails

SMS

How did you hear about us

Google

Social Media

Flyers

Referral

Walk by

Voucher

Event

Referred By

Type of Advertisement

To determine your skin type, please tick one of the following

I – White ( Always burns, never tans )

II – White ( Mainly burns, sometimes tans )

III – White / Asian ( Sometimes mild burns, average tan )

IV – Moderate Brown ( Rarely burns, tans with ease )

V – Dark Brown ( Very rarely burns, tans very easily )

VI – Black ( Never burns )

PRE-TREATMENT QUESTIONS

Have you had sun exposure including solariums/spray tans in the last 4-6 weeks

Yes

Have you previously had IPL/Laser treatments

Yes

Have you previously had cosmetic injections (eg, Anti-wrinkle or Fillers)

Yes

Are you on Acne medication?

Yes

Have you had any chemical peels or Skin Needling done in the last 4 weeks?

Yes

If answered yes to any questions above, please explain in further detail

Do You Have Any Of The Following Concerns?

Lines/Wrinkles

Volume Loss

Lip Enhancement

Sun Damage

Active Breakout

Acne Scarring

Redness

Pigmentation

Enlarged Pores

Ingrown Hairs

Please explain any concerns in further detail:

Are you currently under a Doctor’s care?

Are you allergic to anything?

Do you have an Aspirin allergy?

Are you on any blood thinners?

Are you on any medication?

Do You Have Any Of The Following?

Blood borne infections (HIV, Hepatitis C)

Yes

Cold sores

Yes

Diabetes

Yes

Skin cancer

Yes

Hormonal imbalance

Yes

Active infections

Yes

Skin disorders

Yes

Keloid scarring

Yes

Epilepsy

Yes

Photosensitising drugs

Yes

If answered yes to any questions above, please explain in further detail:

I have been advised of the following

All information regarding my treatments at Eden Laser Clinics has been provided both verbally and in writing. This includes, but is not limited to, my treatment plan, pre and post treatment care and potential adverse reactions, with all of my questions being satisfactorily answered. I am aware I must inform the clinic if anything changes in regards to the information provided at this consultation.
I understand there is no guarantee of complete effectiveness of treatments due to various reasons outlined in the consultation, and I will follow the recommended treatment plan to ensure the best possible results are achieved.
While every precaution has been taken to prevent side effects, they can and sometimes do occur. They may include temporary discomfort, redness and swelling, colour changes such as hyper & hypo pigmentation.
If skin lightening (hypo pigmentation) or darkening (hyper pigmentation) occurs, it may take several months to resolve and in some cases may be permanent
After care is required to achieve optimum results and ensure that risk is avoided where possible. This has been completely explained during the consultation and I understand that if the pre and post care advice is not followed, there may be negative side effects.
I have read and received a copy of the Client Information sheet, after care instructions and a copy of this Consent Form
I acknowledge that I have been recommended by the therapist to use specifically chosen aftercare products, which have been specifically formulated for optimum results.
I understand that using other products purchased elsewhere may not offer the same result and/or potentially irritate the treated area
I consent to photographic documentation of treatment. Photographs will not be used for advertising without my consent.
I understand the fee structure and the cost of undergoing the treatment.
I accept that my pre-paid treatments are not transferable or refundable
I accept all risks of treatment and consent to undergoing treatment

In relation to my initial and all subsequent treatments I advise that:

I am NOT tanned from any source, including sun exposure, tanning lotions, spray tan, solariums etc.
I do NOT have a history of abnormal scarring
I have NOT taken the drug Roaccutane in the last 6 months
I do NOT have any blood borne infections
I have NOT had any deep chemical peels or laser resurfacing in the last 6 months
I am aged 18 years or over (otherwise guardian to sign)
I am NOT pregnant

Cancellation/No Show Policy

Eden Laser Clinics have a 24hr cancellation policy. If cancellation occurs less than 24hrs or the client does NOT show up for their prepaid appointment at the time it was booked, this session will be forfeited. If this treatment is PAYG, the client will be required to pay a 50% deposit for their next booking.

Please do NOT sign this form until you have read and understand the contents. If you have any questions or concerns, please ask your therapist. By signing below, you acknowledge you have read, understood and accept the terms and conditions outlined in Eden Laser Clinics treatment consent form, and all information you have supplied is true at the time of signing this form. If any of your medical or personal circumstances change, you must notify the clinic you attend immediately so we can update your file for future treatments.

When a prepaid package of up to 6 treatments is purchased, all treatments must be redeemed within 18 months of the purchase date. Any left-over treatments will expire. When a prepaid package of 7 or more treatments in purchased, all treatments must be redeemed within 24 months of the purchase date. Any left-over treatments will expire.

Client name:(Required)

Client signature:(Required)