Energist UltraPlus VPL™ System
User Manual
SD1-43 Issue 3 (CCF 296)
99
Client Consent to Skin Rejuvenation 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 rejuvenation by the
Energist ULTRA
VPL™ varies from person to
person and therefore the response to treatment can also vary.
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 the first treatment I may not see an immediate effect and will need
to have a second/third/fourth future treatment.
5. I understand that there is a
very slight
possibility, following treatment, that depigmentation 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.
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
Poor Test
Although my test results have been below average, I agree to the complete treatment with the
Energist
ULTRA
VPL™ and I am aware that the response of the whole area is likely to be similar.
……………………………….… ……………………….
Patient 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
