The Skin Edit by Melissa Jordan

    The Skin Edit · Abbotsford, BC

    Elite iQ™ Laser Hair Removal
    Intake & Consent Form

    Please complete all sections before your first treatment. Your answers help determine whether treatment can be performed safely.

    1. Client Information

    2. Medical & Skin Health Screening

    A Yes response does not automatically prevent treatment, but may require further assessment, treatment modification, postponement, or medical clearance.

    Do you have any current or chronic medical illness or condition, including diabetes, autoimmune or immune-suppression conditions, blood disorders, cancer, active bacterial/viral infection, heat urticaria, photosensitivity disorder, or a condition that may affect healing?

    Do you have a current or chronic skin condition, including vitiligo, eczema, melasma, psoriasis, allergic dermatitis, skin cancer, or a collagen/connective-tissue disorder?

    Are you currently under a doctor's care for a medical condition?

    Do you take prescription/non-prescription medications, vitamins, herbal products or supplements regularly?

    Do you use systemic/oral steroids such as prednisone or dexamethasone?

    Do you have allergies to medications, latex, topical products or other substances?

    Are you pregnant, could you be pregnant, or are you currently breastfeeding?

    Do you have a history of herpes simplex in the area to be treated?

    Do you have a history of keloid or hypertrophic scarring?

    Do you have a history of light-induced seizures?

    Do you currently have open sores, lesions, irritation or infection in the treatment area?

    Have you had radiation therapy in the area to be treated?

    Have you ever received gold therapy (chrysotherapy/aurotherapy or gold sodium thiomalate)?

    3. Medications, Products & Recent Exposure

    Within the last 6 months, have you used anticoagulants/blood thinners, photosensitizing medications, or other medications that may affect skin response or healing?

    Within the last 3 months, have you used glycolic acid, AHA/BHA products, exfoliating/resurfacing products, or had resurfacing treatments in the area?

    Have you used isotretinoin/Accutane® within the last 12 months?

    Have you used tretinoin/Retin-A®/Renova® or another prescription retinoid within the last 6 months?

    Within the last 4–6 weeks, have you had significant/unprotected sun exposure, used a tanning bed/lamp, or applied self-tanning products to the treatment area?

    Do you have tattoos, permanent makeup, implants, fillers, or injectable treatments in or near the area to be treated?

    4. Laser Hair Removal — Treatment Information & Risks

    How it works. The Elite iQ™ laser delivers an intense burst of light that is absorbed by pigment associated with the hair follicle. Protective eyewear must be worn by the client and all personnel in the treatment room.

    What you may feel. Treatment can be uncomfortable and may feel like a pinprick, snapping sensation or heat. Temporary warmth or sensitivity may continue for several hours.

    Expected reactions and possible risks. Redness and swelling may last from several hours to a few days. Possible adverse effects include blistering, burns, crusting, changes in skin texture, infection, scarring, and temporary or permanent hyperpigmentation (darkening) or hypopigmentation (lightening). Individual response varies.

    Results. Hair grows in cycles, so multiple treatments are typically required. Results vary between individuals, and no specific result or permanent level of hair reduction can be guaranteed.

    Pre- and post-care. I understand that sun/tanning exposure and failure to follow the pre- and post-treatment instructions provided by The Skin Edit may increase the risk of complications. I agree to treat the area gently, follow the instructions provided to me, and use broad-spectrum UVA/UVB sunscreen of SPF 30 or greater as directed.

    5. Client Acknowledgement & Consent

    6. Photography Consent

    Clinical photographs of the treatment area before and/or after treatment: This selection applies to clinical treatment documentation only. Any separate marketing or promotional use requires separate permission.

    7. Signatures

    By typing my full name in the signature field, I acknowledge that it represents my electronic signature and confirms my consent to the Elite iQ™ laser hair removal treatment identified above.

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

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