Energist UltraPlus VPL™ System
User Manual
SD1-43 Issue 3 (CCF 296)
98
Skin Rejuvenation Consultation Form
Client Number:
Notes:
Client Name:
Date of Treatment:
Operators Name:
Date:
Please answer the following questions:
Skin Type
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Dry
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Oily
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Normal
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Patchy
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Sensitive
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Prone to pigmentation
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Open pores
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Other:
Previous Treatment Methods
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Electro Surgery
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Laser
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Acid Peels
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MicroDermabrasion
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Other:
Areas to be treated:
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Abdomen
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Armpits
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Back
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Bikini
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Buttocks
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Cheeks
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Chest
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Chin
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Ears
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Eyebrows
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Feet
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Fingers
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Forearms
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Upper Arms
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Upper Lip
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Hands
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Lower Legs
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Neck
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Shoulders
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Thighs
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Other:
Expectations:
1. What are your realistic goals?
2. What concerns do you have regarding treatment?
3. Do you have any questions regarding the treatment procedure?
Client
Signature: Consultant
Signature:
Consultant notes: Is this client suitable for treatment? YES/NO If no, why?
If yes, have you explained: treatment/completed medical history/witness signed consent/addressed any
concerns/explained pre- and post-treatment care procedures?
