* Client Consultation Form

Skin Rejuvenation/Permanent Hair Reduction Treatments PLEASE NOTE: if you are under 18 years of age a Parent/Guardian MUST BE PRESENT and BOTH SIGNATURES ARE REQUIRED before commencement of treatment.

A) Personal Information

- -


B) Medical History
NOTE: It is important to answer the following questions truthfully, as incorrect information could impede results and pose risk to you.


I understand that I am a candidate for pulsed light treatment(s) (hereinafter referred to as the "procedure"). I have reviewed and understand the information given to me and I have discussed all aspects of the specific procedure that I am to receive.

The nature of the procedure, the possible complications and risks as well as the possible benefits of the procedure, the alternatives to the procedure and the risks and benefits of those alternatives have been explained to me in a language and in terminology that I understand. Representative staff including the operator/technician who will be performing the procedure and others who represent the organization and may have been engaged in the consultation describing the procedure (hereinafter the "staff") have answered all of my outstanding questions about the procedure. None of the staff have made any promises or warranties or guarantees as to the success or effectiveness of the procedure. The goal of the procedure and the outcome can be influenced by many factors. I understand that 15% if the population does not respond to pulsed light treatments. I also understand that there may be a requirement for more treatments than originally anticipated. I agree to pay the fee quoted and I understand that all fees quoted are non-refundable.

I understand that there are numerous risks and complications, both known and unknown, connected to the procedure. Studies and experience with these procedures have included, but are not limited to, these potential complications/side effects; 10-20% chance of developing hypo/hyperpigmentation, purpora, bruising, blistering, crusting, freckles and brown spots may lighten and disappear, pimples, redness and swelling, and recent reports have indicated 10% of females being treated in the neck area have documented a slight increase in hair growth. I understand that if I have a history of cold sores or genital herpes I may require pre and post treatment with anti-viral medications. I understand that if I am using topical anesthetics I am solely responsible for their effects in combination with the procedure. Regarding hair reduction pulsed light treatments, I agree that I will not tweeze, wax, thread or have electrolysis done in the area to be treated for four (4) weeks prior to the procedure. I agree I have not been actively tanning or using tanning products for a period of four (4) weeks prior to the first treatment and I agree not to tan or use tanning products at the treatment site while undergoing the series of treatments. I agree to protect my skin with a minimum of a SPF 30 for each four week interval post any procedure at the treatment site.

I understand that the procedure is a relatively new procedure and that minimal data exists concerning its long term safety and effectiveness. I understand that certain medications that I am on which are know to be photosensitizing, will increase my chances of contraindications including pigment changes and blistering. I understand that I will need certain post-care which has been explained to me. If at any time after the procedure I require additional medical attention related to the procedure, I will contact staff within 24 hours of the initial care. I have had the opportunity to ask questions about the procedure and all of my questions have been answered satisfactorily. I understand that in order to achieve the best possible results, I agree to the treatment intervals staff prescribes for me. I give staff permission to use the data associated with my treatment for research purposes. I understand that my name and personal identifying information will remain confidential, unless I give written permission to disclose this information (client may delete this clause when choosing not to participate in research activities).

I am not under the influence of any sedative. I am of clear mind and understand the nature of the procedure and the possible risks related to the procedure.

I understand that by signing below, I am indicating that I have read and understood the information in this patient consent form, that I have been verbally advised about the procedure, that I have had an opportunity to ask questions and that I authorize and consent to the performance of this procedure.


TREATMENT PROTOCOL
1. An approximate amount of treatments shall be scheduled to achieve the desired results during the first visiting. 2. SILK MEDSPA does not accept responsibility if you (the Patient) does not comply with the amount of treatments discussed and recommended at the time of the initial first visit. This applies to all Silk MedSpa services. 3. You will be advised as to the time required between each treatment session, it is important that the advised times required between each treatment be followed, as missing or rescheduling treatments will prolong your final results. "Please try and attend all your pre booked appointments as we want to achieve the best possible results, and we can only do this by working together.

CONSULTATION FEES
1. An initial consultation are free of charge to all new patients.

BOOKINGS
1. All following appointments will be pre booked at the end of a treatment session. 2. The pre booking system guarantees the availability of the time and day for your next treatment. If you cannot pre book directly after your appointment due to work commitments, rosters, etc, notify Silk Medspa ASAP as to when you can attend your next appointment, as we cannot guarantee appointment availability if bookings are not made well in advance. 3. Silk Medspa requires 48 hours notice to reschedule or cancel an appointment via email or telephone only, or a $50 fee will be applied to your next appointment.

TREATMENT COST
1. All new patients must pay the amount owed in full for all package deals. 2. All new patients and existing clients after purchasing will not be eligible for a refund after paying full amount. Unless patient gives Silk Medspa a 48 hours notice after the first treatment due to small side effects that client received during treatment and for this reason the machine isn't suitable for the patient. 3. Silk Medspa charges a $50 shaving fee for anyone who needs it during their session.

As a patient of SILK MEDSPA I have read the information and have answered the above questions to the best of my ability and the information provided is current. I authorize SILK MEDSPA to collect my personal and medical information as documented above in order to contact me, and give permission to leave messages regarding appointments at any of the contact numbers I have provided above. I understand that I am responsible for the full payment of each treatment I receive. I will give 48 hours notice to cancel an appointment, or I may be held responsible for a fee of the missed appointment.

Form Login Code is Here (Visible to Admins Only)