PatientPop
IPL Sheerwave 360 – Photo-RejuvenationMutual Consent Last Name_________________________ Given Name: ______________________________ Phone No.: (____) _____-_______ I was informed the end result varies from person to person depending on the following factors: - Adherence to the treatment schedule recommended by the technician (regularity & consistency) _____ (int) - Hormonal imbalance (may require additional treatments) _____ (int) ??Health Declaration: - I am not prone to keloid (hypertrophic scars) _____ (int) - I do not suffer from photosensitivity. _____ (Int) - I do not have metal implants. _____ (int) - I do not suffer from diabetes._____ (int) - I have no skin allergies._____ (int) - I have no medical problems that can delay the healing process._____ (int) - I am not pregnant._____ (int) - I am not taking photo-sensitizing drugs. _____ (Int) - I do not have herpes simplex (cold sores). If I am prone, I am required to take anti viral medication as instructed. _____ (Int) - I do not have the AIDS virus (HIV). _____ (Int) - I do not have cracked very dry and /or infected skin conditions. _____ (Int) - I have not received cosmetic filler or botulism toxin injections within the past month___ (Int)- I am not taking anti coagulant medications___ (Int)- I do not have permanent make up_____ (Int) In case of doubt regarding the Health Declaration, a note from your physician will be required. _____ (Int) To be avoided pre IPL treatment: I did not use chemical peels, retinoic acid (vitamin A or retinol), glycolic acid or AHA 60 days before my treatment. _____ (Int) I stopped using Accutane 6 months before my treatment. _____ (Int) I have not exposed the treated area to the sun/tanning bed or applied self tanning products for two weeks before my treatment. _____ (Int) Post-treatment recommendations: I will not have micro-dermabrasion, RF, laser, etc. for 30 days after my treatment. _____ (Int) I will only use the topical products and nutritional supplements recommended by the technician (cleanser, exfoliant, moisturizer, SPF 30) for 30 days after treatment_____ (int) I will avoid hot baths and strenuous exercise for 24 hours after my treatment. _____ (Int) I will not expose the treated area to the sun / tanning bed for two weeks after my treatment. ___(Int) If scabbing results from the treatment, I will not scratch/pick/play with/remove it. ___(Int)I will to keep the technician it informed immediately if any complications arise. _____ (Int) Side Effects: - IPL treatments may cause slight redness, intense redness, swelling of the treated area (edema), tenderness, tingling and/or darkening of the skin. Most effects are temporary and disappear within ten days. _____ (Int) - In cases where persistent redness or burning, apply cold compresses and consult a doctor. _____ (Int) My signature and my initials on this document confirms that I have read and I understand this agreement by mutual consent and that I agree to receive treatments with the Sheerwave IPL 360 a division of Platinum Equipment 4190777 Canada Inc.I will receive a copy of this agreement. I will not take any legal recourse against the facility or its affiliates that performed treatments using the Sheerwave IPL 360. Date: _____________________ ___________________________________ _____________________________________ Client Signature Signature of technician Name and signature of parent or legal guardian if patient is under 18 years of age: ____________________________________ ................
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