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Led light Therapy Treatment Consultation Form
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Date Of Birth
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Address
*
Mobile
Doctor’s Name
*
Doctor’s Address
*
Emergency Contact Name
*
Relationship
*
Emergency Telephone Number
Patient skin type
*
White or very pale
pale white with beige tint
Beige to light brown
Light to modern brown
Medium to dark brown
Dark brown to Black
Which skin care products do you use ( Face )
*
Yes
No
Which skin care products do you use ( Neck )
*
Yes
No
Do you regularly use a face cream with an SPF?
Yes
No
. Have you undergone any cosmetic/aesthetic treatments in the last 24 hours?
*
Yes
No
If YES please list.
Details
Next
Are you currently undergoing any other aesthetic treatments?
*
Yes
No
Do you use sunbeds or are regularly exposed to sun?
*
Yes
No
If YES please list.
Do you smoke?
*
Yes
No
Do you have any allergies?
*
Yes
No
8. What are your goals and expectations of the treatment?
What are your primary skin concerns?
Do you have any other aliments?
i.e a cold, coldsores, headaches, fatigue, hayfever, PMT, stiffness, aches & pains, facial bruises etc
How would you rate your stress levels?
*
Rate 1 out of 10
Rate 2 out of 10
Rate 3 out of 10
Rate 4 out of 10
Rate 5 out of 10
Rate 6 out of 10
Rate 7 out of 10
Rate 8 out of 10
Rate 9 out of 10
Rate 10 out of 10
Precautions and Contra – indications for treatments
Antibiotics
*
Tetracyline group: Doxyclyline, Oxytetracycline etc
Quinolone group: Ciprofloxacin, Ofloxacin, Levofloxacin
Sulfonamides: sulfamethoxazole/trimethoprim
If yes the treatment can be administered as long as the medication has not been taken in the last 5 days
Nonsteroidal anti-inflammatory drugs (NSAIDs)
*
Naproxen, Celecoxib
If yes, the treatment can be administered as long as the medication has not been taken in the last 5 days
Diuretics
*
Furosemide, Bumetanide, Hydro-chlorothiazide
If yes the treatment can be administered as long as the medication has not been taken in the last 5 days
Retinoids
*
Roaccutane/accutane
If yes the treatment can be administered as long as the medication has not been taken in the last 5 days
HMG-CoA reductase inhibitors
*
Statins (atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin)
If yes the treatment can still be administered at the discretion of the patient as long as they report no increased sensitivity to sun since commencing statins
Epidermal growth factor receptor inhibitors (treatment for lung cancer)
*
Cetuximab, panitumumab, erlotinib, gefitinib, lapatinib, vandetanib
If yes please consult your physician before commencing a course
Antifungals
*
Terbinafine, Itraconazole, Voriconazole, Griseofulvin (Grisovin)
If yes the treatment can be administered as long as the medication has not been taken in the last 5 days
Anti Arrythmic drugs
*
Codarone, Aratac, chlorpromazine
If yes it is at your discretion whether you commence a treatment
Anti-arthritic
*
Ridaura, Gold 50
If yes the treatment cannot be administered
Anti-arthritic
*
Azathioprine
If yes the treatment can be administered as long as the medication has not been taken in the last 5 days
Anti-Cancer drugs
*
Ledertrexate/Methotrexate
If yes the treatment can be administered as long as the medication has not been taken in the last 5 days
Precautions and Contra –indications for treatments
1-Are you Pregnant?
*
Yes
No
5- Are you currently taking St John’s Wort or other herbal remedies?
*
Yes
No
2-Do you suffer from epilepsy or seizures triggered by light?
*
Yes
No
4-Do you suffer from light induced migraines?*
*
Yes
No
3-Do you suffer from a photosensitive disorder?
*
Yes
No
If you answered yes to question 4 or 5, then it is at your discretion whether you commence a treatment.
*Although uncommon the light may induce a migraine attack. *St John’s Wort taken in very large amounts (more than the RDA) may cause some people to be slightly more sensitive to light.
(A photosensitive disorder describes a condition which means that you are sensitive or react to normal amounts of light. Photosensitive disorders include Porphyria, Lupus erythematosus, photosensitive eczema and Albinism). If you answered yes to any of these questions, then unfortunately you are not suitable
I confirm that I have answered all the questions to the best of my knowledge and understand that withholding necessary information about my health and medication may increase my risk of possible side effects
Name
*
Date
*
Signature
*
Clear Signature
Clinician (witness)
*
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Home
About us
Our Service
Hair
Beauty & Laser
Book Online
Hair
Beauty & Laser
Wedding
FAQ
Forms
Led light Therapy Treatment Consultation Form
Informed Consent For Chairside Teeth Whitening Treatment
Patient Consent Form For Diamond Microdermabrasion Treatment
Patient Consent Form For Micro Needling Treatment
Patient Consent Form For Laser Hair Removal Treatment
Products
Contact