Please complete this form at least 24 hours prior to your patch test Step 1 of 4 25% Welcome to Metro Laser ClinicTo answer questions and give you the chance to get the very best results & convenience: there are a few short audio/video presentation clips which watching will really assist.Name* First Last Preferred name to be addressed by if differentHow should we address you? She/Her Ms He/Him Mr Them/They Mx Prefer not to say Date* Date Format: DD slash MM slash YYYY Address* Street Address City ZIP / Postal Code Email* Enter Email Confirm Email Phone*Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920OccupationWhat areas are you coming for laser treatment on?*Where did you find out about Metro Laser Clinic?*Have you already purchased sessions online?*YesNoHow many sessions did you purchase if yes?Please tell us more if you've had Laser or IPL treatments before enter none if you haven't:* Your Health & Medications https://youtu.be/lz-iWFyzbRUYour Doctor's Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix Last Doctor's Address Street Address Address Line 2 City Please tell us of any medical conditions you have - if none type 'none'*Please tell us of any medications you are currently taking if none type 'none':*Hormones for transitioning - please give us more details of any hormone treatments and the duration to date to alloww us to best assess the optimal laser energyAre you pregnant, have a light allergy, history of cancer, auto immune condition, taken anti acne medication (Accutane) in the last six months or have photosensitivityYesNone of these conditionsSome of thesePlease confirm you have watched our info video* Yes I watched it No I haven't Can't access it Have you a deep tan from a vacation in the last 4 weeks on the area to be treated or fake tan?*YesNoYour skin colour/type*1 Very Pale2 Pale with beige tint3 Light Brown/Mediterranean/Light Asian4 Dark Brown/Dark Asian5 Light Black6 BlackWhat happens when you stay too long in the sun?*0 Painful redness, blistering, peeling1 Blistering followed by peeling2 Burns sometimes, followed by peeling3 Rarely burn4 Never burnTo what degree do you get browner?0 Hardly or not at all1 Light colout tan2 Reasonable tan3 Tan easily4 Turn darker brown quicklyPlease tell us if you've had any of these treatments in the last 2 years on the area to be treated [enter 'none' for none] : Glycolic Acid (over the counter) Less10% Retin-A, Differin Renova, Adapin Sunburn Moderate peel Light peel Liposuction Dye laser Accutane (oral) Photoderm (spider veins) Implant surgery, Deep peel, Laser resurfacing , Burns, Surgical scars, Skin graft*Please tell us if you've had aesthetic treatments like botox, chemical peels, microdermabrasion of fillers on the area to be treated [enter 'none' if none]*enter 'none' if nonePlease tell us if you have any of the following and more about the condition: Diabetes, Keloid scarring, Thyroid condition, Melasma, Vitiligo, Pigmentation disorders, Epilepsy or anxiety disorders [Please type 'none' if none]*enter 'none' if noneAre you photosensitive, taking St Johns Wort, have Lupus or on any medications which require you to stay out of the sun?*YesNoNot sure Almost there! Consent Form. Please type I agree where required to indicate you understand and consent to proceed. I authorise therapists of Metro Clinic to perform the laser treatment for hair removal using the Polaris Long Pulsed Nd:YAG Laser. I understand that they has been trained at the Polaris training academy under the guidance of a Qualified Laser Operations Trainer and have the standard required by Polaris to operate this equipment or have Advanced required Level 4 certification in Laser & Light . I understand that the laser treatment for unwanted hair with selected laser light at 1064nm has been shown in clinical studies to be a safe and effective alternative to methods used for removing unwanted hair such as shaving, waxing, chemical epilation and electrolysis. I have been specifically advised that: (When you have read and understood each section please initial) 1: The clinical evaluation of laser epilation is still ongoing but initial studies of patients treated in 1996 show arrest of hair growth in the treated area from time of initial treatment until current date. I have been correspondingly advised that the number of treatments and the length of each treatment can vary from person to person and is dictated by size of area, density of hair, colour of hair and colour of skin. I have been further advised that only hairs in their active growing stage can be successfully treated. For the above reasons I acknowledge that it is not possible to be entirely accurate in determining the number of treatments required to obtain permanent hair loss. *Please type 'I agree' to indicate permission*2: There is a risk of temporary hyperpigmentation (brown discoloration) or hypopigmentation (lightening of the skin). In very rare cases this may be permanent. 3: Exposure to the sun either directly before or after the treatment is not recommended. 4: To enable the laser to effectively remove all the growing hairs, it is possible but highly unlikely, that the light intensity may generate slight blistering of the skin that might cause temporary scabbing. These accepted conditions are known and recognised, and will resolve themselves in a relatively short time. No permanent marking is likely, although in rare cases marking may persist. Removal of make up and foundation is essential prior to treatment by clients receiving treatment to facial areas. 5: I acknowledge that I have been advised that on rare occasion’s hair removal by laser might not be successful. I agree to inform the practice if have any changes to medication or develop any medical conditions between appointments. *Please type 'I agree' to indicate permission*I have been fully informed of the nature and purpose of the procedure, expected outcome and possible complications. I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed with treatment is based solely on my expressed wish to do so. Due to operational reasons for laser maintenance Metro Clinic may have to reschedule your appointment. Clients are requested to give 24 hours notice when rescheduling, Metro Clinic will endeavour to re-allocate any cancelled appointments within this time to avoid the cancelled treatment being considered as part of any treatment plan. I have been given the opportunity to ask questions and hereby certify that I have read and fully understand the contents of this consent form before affixing my signature below. Should my medical condition or medications change during my treatments I agree it is my responsibility to inform Metro Laser Clinic. I also agree it is my responsibility to give adequate notice 24/48 hours cancellation as indicated or I will be invoiced for missed appointments at late notice that the clinic is unable to re-allocate. *Please type 'I agree' to indicate permission*I understand I am required to comply with COVID restrictions and will not attend if I have been required to self isolate when an appointment is scheduled & will inform the clinic if I am currently experience sysmptoms to cancel my appointment & agree my temperature will be taken on arrival.. *Please type 'I agree' to indicate permission*Almost there... **Temporary COVID measure - keypad disabled - please note currently you must remain outside until asked into the clinic to comply with 2 maximum persons in clinic policy. Remenber your mask before entry. You can also purchase plans from us cheaper than anywhere else and we appreciate if you refer friends direct to us. You'll find a printed consent form that you need to initial and sign on arrival. You may reschedule appointments on our online booking system following the links at the bottom of the appointment email. The easiest way to contact us is on the clinic mobile by text 07739 479682 if you're delayed etc.
