Consent for IPL Treatment Please complete all fields marked with * GENERAL INFORMATION Name * First Name Last Name Answer YES OR NO to the following questions: Have you experienced any unprotected sun exposure, used topical tanning creams or tanning beds in the past 4 weeks? * No Yes Are you pregnant or breastfeeding? * No Yes Are you taking any photosensitizing herbal supplements such as St. John's Wort or Ginko Biloba? * No Yes Have you been on antibiotics in the past 2 weeks? * No Yes Diseases which may be stimulated by light such as Epilepsy, Systemic Lupus Erythematosus, or Porphyria? * No Yes Inflammatory skin conditions (dermatitis, active acne, melasma, etc..)? * No Yes Are you using any topical medications or cosmetic products containing retinols, AHAs or BHAs? * No Yes Presence or history of cold sores or herpes simplex virus? * No Yes Active cancer (currently on chemotherapy or radiation) ? * No Yes Previous skin cancers? * No Yes History of keloids? * No Yes Have you taken isotretinoin (Accutane) in the past year? * No Yes Medical history of Koebnerizing isomorphic diseases (vitiligo, psoriasis)? * No Yes Any known allergies? * No Yes Any tattoos, permanent makeup, or previous BB Glow treatments over the area to be treated? * No Yes Hormonal or endocrine disorders (PCOS or uncontrolled diabetes)? * No Yes Any Botox or other cosmetic injections performed in the past 4 weeks on the area to be treated? * No Yes Please specify below if you answered YES to any of the previous questions. Fitzpatrick Skin Typing Please answer each question carefully. What is your eye color? * 0 - Light blue or gray 1 - Blue or green 2 - Hazel or light brown 3 - Dark brown 4 - Brownish black What is the natural color of your hair? * 0 - Red, sandy red 1 - Blonde 2 - Dark blonde, light brown 3 - Dark brown 4 - Black What is the color of your skin in unexposed areas? * 0 - Reddish 1 - Very pale 2 - Pale with beige tint 3 - Light brown 4 - Dark brown Do you have freckles on sun-exposed areas? * 0 - Many 1 - Several 2 - Few 3 - Incidental 4 - None What happens when you stay in the sun too long? * 0 - Painful redness, blistering, peeling 1 - Blistering followed by peeling 2 - Burns, sometimes followed by peeling 3 - Rarely burns 4 - Never experienced sunburn To what degree do you tan? * 0 - Hardly any or not at all 1 - Light tan 2 - Reasonable tan 3 - Tan very easily 4 - Turn dark brown quickly Do you turn brown several hours after sun exposure? * 0 - Never 1 - Seldom 2 - Sometimes 3 - Often 4 - Always How does your face respond to the sun? * 0 - Very sensitive 1 - Sensitive 2 - Normal 3 - Very resistant 4 - Never had a problem When did you last expose yourself to the sun, tanning bed or self-tanning creams? * 0 - More than 3 months ago 1 - 2-3 months ago 2 - 1-2 months ago 3 - Less than 1 month ago 4 - Less than 2 weeks ago How often is the area you want to have treated exposed to the sun unprotected (without sunscreen, hat, UV protective clothing)? * 0 - Never 1 - Hardly ever 2 - Sometimes 3 - Often 4 - Always POLICIES I authorize Dr. Adam Lee of Vision Wellness to perform IPL treatments on me to improve my dry eye. I understand that this is purely elective, that results vary per individual and that multiple treatments will be necessary to achieve my desired results. I agree to adhear to the before and after care instructions provided to me. It has been explained to my satisfaction. Potential risks and side effects from the treatment may include redness, swelling, discomfort during the treatment, sunburn-like sensation after the treatment, hair reduction over treated areas, and skin discolorations. I am aware that careful adhearance to all advised instructions will help reduce any risk factors. I understand that unprotected sun exposure or tanning of any sort during IPL treatments will dramatically increase the chance of complications. I understand that this is not a covered treatment and Vision Wellness does not bill my insurance for IPL treatments, therefore the cost of treatments will be solely my responsibility. I hearby give consent and authorization voluntarily and release Dr. Adam Lee and Vision Wellness from any claims, implied or stated that I have or may have in the future with any treatment, regardless of the result. I am stating that the treatment and precautions have been fully explained to me in detail and that I fully understand. NO SHOWS AND CANCELATIONS A fee of $35 will be charged to the patient/guarantor if he/she has not checked-in at the front reception desk within 15 minutes of the scheduled appointment time. HIPPA I acknowledge that I have been made aware of Vision Wellness' privacy policies in accordance with the Health Insurance Portability and Accountability Act. By typing my name in the space below I am stating I have read the policies and post care information above and agree to all. * First Name Last Name Thank you!
