IPL Consultation ForM Name First Name Last Name Date of Birth Occupation Email Phone (###) ### #### Are you pregnant? Are you lactating? YES NO Do you have a hormonal imbalance? YES NO Have you been sun-tanning/self-tanning in the past 4 weeks? YES NO Have you had any cosmetic surgery or injectable cosmetic treatments (e.g. Botox or dermal fillers) and if so when last? YES NO Do you suffer from epilepsy? YES NO Do you suffer from diabetes? YES NO Are you light sensitive (photosensitive)? YES NO Do you have a history of cancer? YES NO Do you have any infectious or contagious conditions, or blood borne viruses? YES NO Do you suffer from cold sores (herpes simplex)? YES NO Do you suffer from high blood pressure? YES NO Do you suffer from eczema/psoriasis? YES NO Do you have any metal implants/pins? YES NO Do you have a history of keloid, hypertrophic scarring? YES NO Do you have any allergies? YES NO Are you on any medication that is photo sensitive? YES NO Do you suffer from autoimmune disease/connective tissue disorders? YES NO Skin Pigmentation Disorders? YES NO Are there any other medical conditions that we should be aware of? YES NO Please list any medications you are taking: Are you currently using any of the following: St John’s Wort / Amiodarone / Minocycline / Anticoagulants / Gold Medications / Oral or Topical Retinoids / Oral or Topical Steroids? (if not leave blank) I confirm that the medical history is accurate and complete. Therefore, if there are any adverse effects due to an undisclosed medical condition, our therapists are absolved from any responsibility. I understand that withholding any medical information may be detrimental to my health and safety during which the practitioner agrees to undertake. It is my responsibility to advise my practitioner if there is any change in my medical history. Thank you for filling out the form!
