Client Consultation Form printable pdf download

Client Consultation Form

Clinic Name

Client Name:

Address:

Client Number:

Therapist’s Name:

Operators Name:

Date:

Contraindications

Patients with any of the following contraindications should not be treated with IPL unless a letter from

the patient’s primary care physician is available confirming that the patient can be treated safely.

• Tanned skin (active tan) through sun exposure or tanning bed use in the previous 30 days

(because of increased risk of hyperpigmentation)

• Waxing, plucking, sugaring, or threading depilation treatment of the area in the previous 4-6

weeks (because the follicle has been removed)

• Hypopigmentation (eg, vitiligo)

• Any inflammatory skin condition (eg, eczema, active Herpes Simplex, etc. at the treatment site

because it may aggravate the condition)

• Presence or cancer or current cancer drug therapy

• History of keloid scarring (because any IPL burn may produce a keloid scar)

• Epilepsy (because repeated consecutive flashes may induce seizures)

• Use of St. John’s Wort (herbal remedy) in the past 3 months for depression (due to photosensitivity)

• Use of oral isotretinoin, accutane, or tretinoin in the previous 3-6 months for the treatment of acne

or other dermatological conditions

• Pregnancy; until periods return and breastfeeding is stopped (because hormonal imbalance may

reduce treatment effectiveness)

• Use of drugs for diabetes (due to possible photosensitivity and poor wound healing)

• Use of anti-coagulant drugs (eg, for heart disease)

• Presence of a pacemaker unless the pacemaker manufacturer confirms in writing that it is safe to

treat the patient

• Use of any topical medication, perfumes, deodorants, sun block, essential oils, or other skin

lotions (which could cause photosensitivity – see complete list below

• Presence of surgical metal pins or plates under the tissue to be treated

• Age under 18 years if the establishment is not registered to treat children or if parental permission

is withheld

Client Consultation Form