The Skin Edit by Melissa Jordan

    The Skin Edit · Abbotsford, BC

    5D Laser Facial
    Intake & Consent Form

    Complete the fields below and select an answer for each question. Your practitioner will review your answers before treatment.

    1. Client Information

    2. Medical and Skin History

    Are you pregnant, possibly pregnant, or breastfeeding?

    Do you have a history of cold sores or herpes simplex?

    Do you have an active skin infection, open wound or irritated skin?

    Do you have a history of keloids, raised scars or delayed healing?

    Do you have a bleeding disorder or take blood-thinning medication?

    Do you have an autoimmune condition or reduced immune function?

    Do you have epilepsy, light-triggered seizures or sensitivity to light?

    Do you have diabetes, another medical condition, or ongoing medical care?

    Do you have allergies to medications, latex or skin care products?

    3. Medications and Recent Skin Treatments

    Include product names and exact dates where possible. Do not change prescribed medication without advice from your prescribing clinician. Your practitioner will advise on treatment suitability and preparation.

    Have you taken isotretinoin or Accutane within the past 12 months?

    Do you use medicines or supplements that may increase light sensitivity, including tetracycline antibiotics or St John's Wort?

    Do you use prescription retinoids, AHA or BHA acids, exfoliants or hydroquinone?

    Have you recently had Botox, Dysport, dermal fillers or other injections?

    Have you recently had a peel, microdermabrasion, laser treatment or surgery?

    Have you recently had a tan, sunburn, tanning-bed exposure or self-tanning products?

    4. Treatment Goals

    5. Practitioner Assessment

    For the practitioner to complete before treatment.

    6. Treatment Information and Consent

    The 5D Laser Facial is an elective cosmetic treatment. The practitioner will explain the specific laser treatment steps, treatment areas, intended benefits, expected recovery and suitable alternatives before proceeding. Results vary, and more than one session or maintenance treatment may be recommended. No specific result is guaranteed.

    Possible temporary effects include discomfort, warmth, redness, swelling, sensitivity or flaking. Possible complications include burns, blistering, infection, cold-sore outbreaks, darkening or lightening of the skin, and scarring. Some pigment changes or scars may be lasting. Protective eyewear must be worn as directed.

    I agree to follow the written preparation and aftercare instructions provided to me, including broad-spectrum SPF 30 or greater, sun protection, and avoiding heat, saunas, swimming, picking or exfoliating for the period advised by my practitioner. I will report unexpected or worsening reactions promptly. If cold-sore prevention is needed, medication must be arranged through an appropriate prescribing clinician.

    7. Clinical Photography

    Permission below applies to treatment records only. Marketing or promotional use requires separate permission.

    8. Typed Signature Acknowledgement

    Please complete all required fields, screening questions, acknowledgements, and signature before submitting.

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