Energist UltraPlus VPL™ System
User Manual
SD1-43 Issue 3 (CCF 296)
97
Client Consent to Hair Removal Using Energist ULTRA VPL™
Client Name: …………………………………….… Phone: ………………………………
Client Address ……………………………………………………………………..…………..
I understand that the procedure is an elective cosmetic procedure and
herby acknowledge the following
:-
1.
I understand that the extent of hair removal by the
Energist ULTRA
VPL™ varies from
person to person and therefore the response to treatment can also vary. Although, in the ideal
patient the
Energist ULTRA
VPL™ treats virtually all the pigmented actively growing hairs
at each treatment, and thus three to five spaced treatments should be sufficient for good
clearance, one cannot guarantee that every single follicle is treated in the chosen area.
2.
I would like the following area of my body to be treated: …………………........................... I
understand that the cost of treatment will be £………………..… per session.
3.
I understand that immediately following treatment (post) the area may appear reddened and
there is a
very slight
chance that small blisters may appear.
4.
I understand also that following treatment I need to wait at least 10 to 14 days to see the full
response and will need to have a second/third/fourth future treatment.
5.
I understand that there is a
very slight
possibility, following treatment, that hypopigmentation
of the area being treated may occur causing the skin to appear paler, or hyperpigmentation of
the area being treated may occur causing the skin to appear dark. These symptoms, if they
occur, are usually temporary and slight but the clinic is unable to guarantee that all normal
pigment returns. I understand that there is a very slight risk of scarring with any skin
treatment but in this case it is
extremely small.
6.
I confirm that I have provided the clinic with any medical details, which may be relevant to
my treatment.
7.
I have read the Hair Removal Fact Sheet and I have been fully counselled.
My signature below constitutes my acknowledgement that I have read, understand and fully agree to
the foregoing consent, the proposed treatment process has been satisfactorily explained to me and I
have all the information which I require. I hereby give my consent and authorisation voluntarily and
release this establishment and its agents of any claims that I have or may have in the future in
connection with the described treatment.
……………………………..…. ………...……………………… …….………………
Client/Guardian Signature Clinic Signature Date
Treatment Check List (Therapist MUST complete before each treatment)
¾
Does the client have any of the contra-indications?
Yes
No
¾
If the Client has gained a tan, was it within the last 4 weeks?
Yes
No
¾
Does the Client have any skin abnormalities which may be of concern?
Yes
No
¾
If the Client has received previous treatments, have they had any problems?
Yes
No
¾
Are you UNCERTAIN of the parameters required to treat the client?
Yes
No
