PERSONAL INFORMATION: Customer Consent Form Step 1 of 2 50% Full name of client:* Address* Street Address Email Address* Contact Number* Age of client:*Date of birth:* Day Month YYYY Gender* How did you hear of us?1) Which treatment and what areas (e.g. legs) are you interested in having?Tattoo Removal: Nevus of Ota: Skin rejuvenation/Photo rejuvenation: Thread Veins: Pigmentation /Sun damaged: Birthmark: Other: 2) Have you used any of the following in the past 30 days? None Sun Beds Self-tanning cream Tanning in the sun 3) When was your last sun holiday, and when is your next sun holiday? 4) Medical InformationDo any of the following apply to you? Please tick those that apply. Heart Disease Burns / Grafter skin Liver / Kidney disease Port wine stain Shingles Steroid or Hormonal therapy Aids Gold injections Haemophilia Polycystic ovarian syndrome Hirsutism Haemangioma Thyroid hormone deficiency Diabetes Melanoma / Moles Anti-coagulants Acne Cancer (or radiation/chemotherapy) Keloid formations / Scars Epilepsy Psoriasis Skin Pigmentation Vitiligo Hormonal Imbalances Lupus Disease Clotting disorders Breast Feeding Anti-inflammatory medication Herpes (or cold sores) Pregnant 5) Specify a medical condition that is not listed above. 6) List any medication that you are taking 7) Have you ever used (or currently using) Retin A or Glycolic Acid?YesNo8) Have you ever used or are you currently using Roaccutane?YesNo9) What products are you currently using on your skin (including body products)? 10) If you have any implants, list the area. 11) Do you have any skin sensitivities or allergies? 12) Have you had any major surgery performed in the last 3 months? 13) Do you consent to photographs of your treatment being used on social media?YesNoIndividual ConsentI hereby authorise MI Laser Clinic to treat me using the AW3® system.YesNoI 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 forma:on “dirty skin” look is commonly seen for up to 10 days aPer treatment. (Light/Laser Treatment Only)Scabbing, Swelling, and bleeding can occur but these are temporary. (Light/Laser Treatment Only) Below are a list of treatment(s) that will apply to me when accepting this consent. Laser Tattoo Removal / Pigmentation / Thread Vein / Rejuvenation / Birthmark Removal Laser treatment is a method of removing tattoos. The purpose of the treatment is to achieve improvements in the appearance of the skin by removing the unwanted tattoo/pigment within the dermis of the skin using the AW3® Laser system. 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 aPer treatment. 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.Date* DD MM YYYY Customer Full Name:* Signature of client:*On completion of your laser treatment, we would be grateful if you could provide us with an outline review & rating regarding your experience with us.Thank you for completing the form, please hand the device back to a member of staff. Price of treatment:* Signature of artist:*
