Consultation Form

First name

Last name

Phone

Address

Birthday

Day

Month

Year

Gender

How did you hear about us?

Have you had laser before?

Yes

If yes, How many sessions?

What areas would you like treating?

Have you had any of the following in the last 7 days?

Self Tanning Cream

Tanning in the Sun

Sun Beds

None of the above

Specify any medical conditions that is not listed above:

List the medication you are taking:

Have you ever used or are using Retin A (retinol) or Glycolic Acid?

Yes

Have you ever used or are using Roaccutane?

Yes

What products do you use on the skin? (Moisturiser, deodorant etc.)

If you have any implants, please list the areas:

Do you have any skin sensitivity?

Yes

If yes, please specify?

Which skin type best describes you?

TYPE 1 - Light, pale skin. (Always burns, never tans)

TYPE 2 - White, fair. (Usually burns, tans with difficulty)

TYPE 3 - Medium, white to Olive. (Sometimes mild burn, gradually tans to olive)

TYPE 4 - Olive, moderate brown. ( Rarely burns, tans with ease to a moderate brown)

TYPE 5 - Brown, dark drown. (Vary rarely burns, tans very easily)

TYPE 6 - Black, very dark brown to black. (Never burns, tans very easily, deeply pigmented)

Informed Consent

I hereby authorise Amie Stubbington to treat me using the AW3® system.

I understand that the reduction/ removal may not be 100%. I also understand that the treatment using the AW3® system may need to be performed in repeated sessions in the future to obtain optimal results.

I have been informed 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 the treatment and they include but are not limited to the following:

• Post-treatment discomfort like localised swelling, redness and mild tenderness.

• Although uncommon the treatment may cause blisters or light burns to the surface of the skin. (Light /Laser Treatment Only)

• Transient hypo or hyper pigmentation may occur and will normally fade in 3 to 6 months.

• Crust formation “dirty skin” look is commonly seen for up to 10 days after treatment. (Light /Laser Treatment Only)

• Scabbing, Swelling, and bleeding can occur but these are temporary. (Light /Laser Treatment Only)

Below is the treatment that will apply to me when accepting this consent.

Hair Removal: Laser 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 AW3® System will not cure any medical conditions causing unwanted hair.

The purpose of the treatment is to achieve cosmetic improvements by reducing hair growth by using Laser to destroy hair follicles

Accepting Terms and Consent*

I agree to follow the post treatment recommendations advised by operator/company above in order to ensure the best possible results. For Light/ Laser Treatments, I understand that excessive heat should be avoided for 48 hours and that exposure to the sun, including sun beds, must be avoided for 30 days before treatment and 30 days after treatment. (AW3 Super IPL and AW3 Super Laser may vary and your specialist can advise) A sun block of SPF 30+ must be used on the exposed skin areas, otherwise it might be possible that blotchy skin pigmentation, hyper- or hypo-pigmentation might occur.

I agree to co-operate with the recommendations of the company or the personnel while I am under their care, realising that any lack of co-operation could result in less than optimum results.

I agree to inform the above operator/company immediately if any adverse effects occur.

I agree to photographic documentation of the treated area prior to treatment.

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. This consent form and cost covers above selected treatments only. Additional treatments can be added to this consent form and will be charged for as per clinic price list, including single shot treatments.

I have been made aware of the risks and I accept these terms and conditions as part of my treatment. We accept no liability for any of the above side effects. By accepting this, I agree to the terms and conditions and in the event of any of the above. I or any of my representative will not pursue the above person / company in any means of compensation.

Full Name

Signature

Signature field is empty.

Date picker