IPL Skin Rejuvenation Consent Form
Treatment Information:
IPL treatments are clinical procedures that require no needles, medications, or surgery. The Etherea MX IPL-SQ treatment is a proven advanced skin care procedure that can significantly improve the appearance of textural irregularities and vascular and pigmentation blemishes.
IPL treatments direct IPL energy into the skin in targeted treatment areas. This energy passes through the skin's outer surface, called the epidermis, and penetrates into the lower layer of the skin, called the dermis. The treatment utilises specific filters to control the wavelength of the IPL energy to improve the appearance of acne, rosacea, sun-damaged skin with pigmentation abnormalities, and vascular blemishes such as spider veins.
IPL energy also stimulates a type of skin cell called a fibroblast, which is known to produce new collagen proteins within the skin. Over several treatments, this new collagen softens the appearance of wrinkles, oversized pores, and textural irregularities.
Before beginning an IPL treatment program, you must first attend an assessment and information consultation with one of our Nurses or Aestheticians, during which your skin type, facial cosmetic concerns, expectations, and goals will be assessed and discussed. The estimated duration and cost of each session or series of sessions will also be provided to you during this time. If you are a qualified candidate, you will need to undertake several test patches of treatment in the indicated area at varying intensity levels. This allows your practitioner to understand how responsive your skin is and ensure a safe treatment is delivered.
You will generally require 3-5 treatments, and this varies depending on your particular indication, skin quality, skin goals and the degree of correction required.
You must not have UV-tanned skin for four weeks before an IPL treatment or apply artificial tanning products to the treatment areas for at least two weeks before an IPL treatment. Failure to comply with this could result in serious harm (burned skin) and subsequent scarring of your skin.
Treatment
Your practitioner will cleanse your skin and apply a layer of ultrasound gel in the treatment area to help deliver the IPL energy and cool the skin surface.
During the procedure, your practitioner will assess your comfort levels and adjust the treatment parameters where required. Some level of discomfort within the skin is expected; some areas may be more sensitive than others.
When delivering the IPL energy to the skin, it is essential to cool the skin to avoid injury to the skin surface. A cooling crystal is integrated within the Etherea MX IPL SQ light guide applicator to assist with patient comfort and safety.
Following each Etherea MX IPL SQ treatment, the skin may experience a minor degree of redness and puffiness, with some tingling or discomfort, which usually disappears in as little as 1 hour or up to 2 days.
You may apply makeup immediately after treatment and can return to your regular daily activities without downtime. A comprehensive skin care program will be recommended for you to use in conjunction with your IPL treatments to reduce the risk of complications and assist in achieving the best results for your indication.
You must apply daily sun protection with UVA/UVB filters and an SPF of at least 30. We require you to commit to using this every day and avoiding sun exposure, artificial sun beds, and artificial tanning products in the treatment areas as a condition of the IPL treatments you receive with us.
Alternative Treatments:
Your practitioner will always advise you of the safest and most effective treatment based on your medical history and skin appearance. However, if you consider the risks of IPL unacceptable, you should also consider the option of no treatment. Other treatments to reduce skin pigmentation and rejuvenate the skin are available, such as chemical peels and microneedling medical skincare, and may be discussed with your practitioner. Alternative treatments for Rosacea and thread veins include needle cautery and medical skincare and may be discussed with your practitioner.
Contraindications:
You cannot have IPL skin rejuvenation treatments if:
You have tanned skin either from UV light exposure or artificial skin tanning products. (No UV-tanned skin for four weeks prior to treatment)
You have a skin type 4, 5 or 6. There is a risk that natural skin colour could be removed (hypopigmentation)
You have had roaccutane/Isotretinoin medication in the last six months.
You have photosensitive epilepsy
You have an active infection or inflammation near the intended treatment area, excluding active acne lesions.
You have open wounds in the intended treatment area
You have an active outbreak of herpes simplex infection (Cold sores) in the treatment area.
You have a history of keloid or raised scarring.
You have uncontrolled diabetes or poor wound healing.
You have blood clotting problems or are taking blood thinning medications.
You are immunosuppressed.
You have a history of post-inflammatory hyperpigmentation
Have uncontrolled hormonal disorders
You have a pacemaker.
You have had facial fillers or botox in the intended treatment area under two weeks prior to IPL.
You think you could be pregnant, are pregnant, or are lactating/ breastfeeding.
You have a loss of sensation in the treatment area.
Cautions:
You need to tell your aesthetic practitioner if:
You take photo-sensitising medications/apply photo-sensitising skincare.
You suffer from recurrent bouts of herpes simplex infections near the intended treatment area, as an IPL treatment may encourage an outbreak.
You have mobility issues.
You use topical retinol or retinoid prescription medications in the treatment area. If used on the intended treatment area, you MUST stop using these four days before an IPL treatment.
You have a history of malignant (cancerous) skin lesions.
Material Risk (the level of significance you personally apply to the risks, side effects or complications of this treatment within your own circumstances):
As with any medical procedure, this treatment carries the risk of side effects or complications. Discuss these risks with your practitioner to fully comprehend their implications. Consider the risks in relation to your personal circumstances, including your health, lifestyle and career and decide if they are acceptable. If not, discuss alternatives or take more time to decide.
Associated Risks:
Photo-Sensitivity: IPL treatments will leave your skin photosensitised for 48 hours after each treatment. You must avoid sunlight. Failure to do so will result in significant redness and swelling and may increase the rare risk of disfiguring and complications like blisters, scarring, or pigment changes.
Discomfort. IPL treatments are very well-tolerated treatments. Patient comfort is optimised with the cooling light guide tip that is integrated into the Etherea MX IPL-SQ applicator to assist with patient comfort. Topical anaesthetic cream cannot be used as this may disguise an overheating of the skin. With each treatment, you may experience a minor and tolerable degree of burning and/or a tingling sensation.
Skin erythema (skin redness) and heat. This is the most common and likely side effect of your treatment with IPL. It is related to the rise in internal skin temperature and is normal. It can be managed by keeping the skin cool following your treatment. It should subside within a few hours. If it does not subside within a few hours, please contact your practitioner for further advice.
Swelling, tingling, or tenderness may occur. For a few days after treatment, you may experience slight discomfort (like mild sunburn) within the skin.
Bruising welts or numbness. Very rarely, some patients may experience this.
Skin wounds. It is exceedingly rare for IPL treatments to cause a blister or skin wound. However, this is more of a risk in darker or tanned skin types. If a blister or skin wound develops, it may take 5 to 10 days to heal and, in extremely rare instances, may lead to a noticeable whitening or darkening of the skin or, even more rarely, a scar. Blisters or skin wounds are much more common if you do not follow the recommended avoidance of sunlight, artificial tanning products, UV light exposure, and fluorescent light exposure post-treatment.
Scarring. Scarring occurs in less than 0.1% of patients. If you have developed a wound and a scar, the scar may become flat and white (hypotrophic) or large and red (hypertrophic), or it may extend beyond the margins of the injury (keloid). Subsequent treatment or surgery may be required to improve the appearance of the scar. In some cases, the scar may be permanent. Failure to follow pre- and post-treatment care instructions may increase the likelihood of a skin wound or scar.
Infection. Because IPL treatments involve no actual cutting, surgery, or skin penetration, infection is exceedingly rare. However, a blister or wound that has formed as a result of IPL treatments may become infected. To avoid infection, it is important to contact your practitioner if you ever experience a blister or wound following an IPL treatment.
Pigment changes. With the IPL energy used in Etherea MX IPL-SQ treatments, there is a small risk (less than one per cent) of temporary hyperpigmentation (increased pigment or brown discolouration) or hypopigmentation (whitening of the skin). Usually, these pigment effects are temporary and resolve over several weeks or months. Permanent hyperpigmentation or hypopigmentation is very rare and may occur in less than one per cent of cases. The majority of patients will be advised to use skin care products throughout their IPL treatment course. These medical skin care products are important to obtain optimal results and reduce complications.
Herpes (cold sores) reactivation. Treatments that induce heat within the skin/hair follicle, such as IPL, carry the risk of an outbreak of herpes (fever blisters/cold sores/shingles) in individuals who already carry the herpes virus. You should manage this as you would normally, such as using over-the-counter cold sore medication. Please contact your practitioner if you experience a severe outbreak following treatment.
Dissatisfaction. Not all facial wrinkles, blemishes, and skin types respond the same to IPL treatments. Your skin’s response may be subject to variation. However, the overwhelming majority of clients who have undergone Etherea MX IPL SQ treatments report a noticeable improvement in the appearance of skin quality and youthful vitality by 40 - 70%. There is a risk that you may not see an appreciable improvement in the quality and appearance of your skin.
Photographs:
We need to take photos of the treatment area to document the original condition before treatment begins and to monitor results and potential changes throughout the treatment process. These photos will become part of your medical aesthetic treatment record at Lumiere Medispa.
You have the right to refuse consent for these photographs. However, please be aware that without this consent, we will not be able to treat you for medico-legal reasons.
If we wish to use your photos for any other purpose, we will always seek separate written consent from you. You have the right to refuse this additional use of your photos, and it is not mandatory to consent to any other photo usage to receive treatment.
Informed Consent:
This consent form is not meant to include all possible risks associated with an IPL skin rejuvenation treatment, as there are both known and unknown side effects and complications associated with any medical treatment. We have written this consent form to ensure you are fully informed of the procedure, the reasons why you may not be able to receive treatment, and the known risks of an IPL skin rejuvenation treatment.
By signing this consent form, you acknowledge and confirm the following:
Risks and complications
You have discussed the potential risks and benefits of an IPL skin rejuvenation treatment with your practitioner, and all of your questions have been answered to your satisfaction.
You understand that medical attention may be required to resolve any complications associated with your treatment. In most cases, except those in an emergency, you should contact your practitioner for advice/treatment.
Medical History
To the best of your knowledge, you have provided the details of your past medical history and will inform your practitioner if this changes before any future treatments.
You understand that withholding aspects of your medical history could lead to serious physical and mental harm.
Contraindications & Cautions
You are not pregnant or possibly pregnant, lactating or nursing, and you will inform your practitioner if this changes before any future treatments.
Fees & Charges
You understand and agree that all services rendered will be charged directly to you, and you are personally responsible for payment.
You further agree, in the event of non-payment, to bear the cost of collection, court costs and reasonable legal fees, should they be required.
Refunds
Fees charged for treatment are for the delivery of a treatment and the accompanying service, which is inclusive of the following;
-Consultation and assessment
-The provision of information and advice
-The provision of the treatment itself, as described above
-Follow-up appointments and aftercare advice and support as appropriate
Whilst we undertake to provide excellent service, factual, honest and ethical advice, safe, expert treatment in experienced hands and only the best products, we cannot guarantee your results. We cannot offer refunds if the results achieved fail to meet your expectations. The successful outcome varies by degree, and how long these effects last varies from one individual to another and cannot be guaranteed.
You understand that whilst you have been advised of a probable result, this should not be interpreted as a guarantee.
You will contact your practitioner if you are unsatisfied with your treatment outcomes.
Aftercare
You have verbally discussed the aftercare required following an IPL skin rejuvenation treatment, and you have been informed that you will also receive this via email. You understand the importance of following the post-treatment advice and agree to follow it.
You understand that failure to follow this advice could lead to serious physical and mental harm.
Photograph Use Consent:
You understand that receiving treatment at Lumiere Medispa requires photographs to be taken of the treatment area. These photographs may be taken before, during, and after each treatment and will form part of your legal medical record at Lumiere Medispa. By signing below, you freely give your consent for your photos to be used solely for this medico-legal purpose. If we wish to use your photos for any other purpose, we will always seek separate written consent from you, and you have the right to refuse.
Valid Consent
By signing below, you acknowledge that you have read and understood this consent form and have had the opportunity to discuss any questions you have with your practitioner to your satisfaction. You consent to receive an IPL skin rejuvenation treatment under the terms of this consent form and understand that you have the right not to consent to this treatment and that your consent is voluntary.
