Client Consultation Form. Clinic Name. Contraindications
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- Godwin Hicks
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1 Client Consultation Form Clinic Name Client Name: Address: Client Number: Therapist s Name: Operators Name: Date: Contraindications Patients with any of the following contraindications should not be treated with IPL unless a letter from the patient s primary care physician is available confirming that the patient can be treated safely. Tanned skin (active tan) through sun exposure or tanning bed use in the previous 30 days (because of increased risk of hyperpigmentation) Waxing, plucking, sugaring, or threading depilation treatment of the area in the previous 4-6 weeks (because the follicle has been removed) Hypopigmentation (eg, vitiligo) Any inflammatory skin condition (eg, eczema, active Herpes Simplex, etc. at the treatment site because it may aggravate the condition) Presence or cancer or current cancer drug therapy History of keloid scarring (because any IPL burn may produce a keloid scar) Epilepsy (because repeated consecutive flashes may induce seizures) Use of St. John s Wort (herbal remedy) in the past 3 months for depression (due to photosensitivity) Use of oral isotretinoin, accutane, or tretinoin in the previous 3-6 months for the treatment of acne or other dermatological conditions Pregnancy; until periods return and breastfeeding is stopped (because hormonal imbalance may reduce treatment effectiveness) Use of drugs for diabetes (due to possible photosensitivity and poor wound healing) Use of anti-coagulant drugs (eg, for heart disease) Presence of a pacemaker unless the pacemaker manufacturer confirms in writing that it is safe to treat the patient Use of any topical medication, perfumes, deodorants, sun block, essential oils, or other skin lotions (which could cause photosensitivity see complete list below Presence of surgical metal pins or plates under the tissue to be treated Age under 18 years if the establishment is not registered to treat children or if parental permission is withheld
2 A doctor s letter should also be obtained before treating patients who are reportedly using quinidine, any anti-psychotic medication, or large combinations of cardiac/diuretic drug or topical steroid creams in the area to be treated, general anesthesia in the last 3 months, local anesthetic treated areas in the past month, and any cases in which you are uncertain about any reported medical condition or medication. Treat with caution and obtain a doctor s letter if you are uncertain about anyone who has: Fake tan Allergies Hormone abnormalities such as polycystic ovarian syndrome Cold sores in the treatment area Previous depilation treatments Reported HIV infection or hepatitis Please answer the following questions: Skin Type Other: Skin Color Treatment Notes White Olive Oriental Indian Afro-Caribbean Other: Skin Conditions Pigmented Patches Sun-Tanned Moles Freckles Acne Psoriasis Eczema Vitiligo Other: Prone to pigmentation changes What other methods of Skin therapy have you used before? Cosmeceuticals Chemical peels Botox Er: YAG / CO 2 Other: Are you undertaking a course of treatment that may make your skin photosensitive? (See attached sheet for information and a list of common drugs.) Yes No If Yes, what type? Do you have any kind of allergies? Yes No If Yes, what type? Do you take medicine for any allergies? Yes No If Yes, what type?
3 PIGMENT/VASCULAR CONSENT FORM 1. I understand that treatment for pigmented and/or vascular lesions is performed with the Quadra Q4 Platinum Series Intense Pulsed Light system which uses electronically controlled high intensity multiwavelength light to heat and destroy pigmented and vascular lesions on the skin. These spots will flake off or fade within three weeks after treatment. 2. I understand this procedure may cause discomfort during treatment and a slight redness and irritation will occur on the skin after treatment. This sunburn-like irritation usually subsides in 12 to 24 hours. The pigmented and/or vascular lesions will slightly darken after treatment prior to fading. In some rare cases side effects may include, but are not limited to, lightening or darkening of the skin, blistering, or skin irregularity. 3. I understand that results vary from patient to patient and that there is a small possibility the procedure will not remove all the pigmented and/or vascular lesions on my skin. I also understand that in order for the procedure to be effective, the following guidelines must be followed: a. Multiple consecutive treatments are performed until the desired level of pigment and/or vascular removal is observed. (Usually two or three treatments.) b. Sunscreen must be worn for at least 3 weeks after treatment. 4. I understand that sun exposure 2 weeks prior to treatment and/or 2 weeks after treatment can possibly cause darkening or lightening side effects of the skin. 5. I understand that other forms of pigmented and vascular lesion removal methods exist. 6. All my questions regarding this procedure have been answered. 7. I understand that the physician may use any pictures taken of me for educational purposes. 8. INDEMNITY: I confirm that the information that I have supplied is true and correct, and that I have read, understood and accept the above-mentioned information. I hereby indemnify the equipment operator, the clinic owners and their staff, the franchiser and their employees and the manufacturer of the equipment from any claims whatsoever. Client Name: Client Signature: Date:
4 Information on Drug-Induced Photosensitivity There are many drugs available at the moment that can cause the skin to become very sensitive to light. Whether these drugs are taken by mouth or applied to the skin a reaction can occur. This reaction is called Drug-Induced Photosensitivity. Therefore, it is very important that you read this information and notify the Doctor/Operator of any drugs that you may be using. Photosensitivity reactions can be divided into two groups: Photo-Toxic Reactions These are dose related and can be seen to a slight degree in people who are exposed to sunlight. Photo-Allergic Reactions These involve the immune system and may be similar to other allergic reactions, swelling, rashes and hives. The drugs cause this reaction by absorbing the Equipment light (which is in the visible part of the spectrum) that is delivered by our system. Types of Photosensitivity Abnormal and extreme sunburn Stinging and burning Vesicles Hives Swelling There is a large variation in the frequency and severity of reactions from client to client. Some clients may blister, have a slight unnoticeable reaction, or will have no reaction at all. For this reason it is advisable that test patches are carried out to determine if any adverse reactions occur. Common Drugs That Can Cause Photosensitive Reactions Antibiotics Dioxycycline (Vibramycin, Vibratabs) Demeclocycline (Declomycin) High incidence. Tetracycline (Achromycin and others) Nalidixic Acid (NegGram) Lomefloxacin (Maxaquin) Especially noted for severe reactions when they occur. Blood Pressure and Heart Medications Hydrochlorothiazide (Hydrodiuril, Oretic and other names) Many drugs contain HCTZ as one of the ingredients. Chlorothiazide (Diuril and other names) Furosemide (Lasix)
5 Amiodarone (Cordarone) - High incidence of drug-induced photo-reactions. Other Drugs Chlorpromazine (Thorazine) Methoxypsoralin PABA and/or PABA esters Used in sunscreens, can cause hives and rashes. Common Drugs That Cause Photosensitive Reactions Less Often Alprazolam (Xanax) Amitriptyline (Elavil, Endep and other names) Benzocaine (Sensorcaine and many other numbing products) Captopril (Capoten) Chloradiazepoxide (Librium) Chloroquine Chlortetracycline Ciprofloxacin (Cipro) Co-trimoxazole (Bactrim, Septra) Dapsone Diltiazem (Cardizem, and other names) Diphenhydramine (Benadryl, Benylin and other names) Enoxacin (Penetrex) Oestrogens (Birth Control Pills, Premarin and more) Fluoracil (5-FU) Glyburide (Diabeta, Micronase, Glynase, and other names) Griseofulvin (GrisPeg, Fulvicin, and other names) Haloperidol (Haldol) Hydralazine (Apresoline) Ibuprofen (Advil, Motrin, and more) Isoniazid (INH) Isotretinoin (Accutane) Methotrexate Minoxidil (Loniten, Rogaine) Naproxen (Naprosen, Alleve, other names) Nifedipine (Procardia, Adalat) Norfloxacin (Noroxin) Nortriptyline (Aventyl, and other names) Ofloxacin (Floxin) Oral Contraceptives Oxytetracycline (Terramycin) Perfenazine (Trilafon) Phenylbutazone (Butazolidin) Phenytoin (Dilantin) Piroxicam (Feldene) Prochlorperazine (Compazine) Promethazine (Phenergan) Protriptyline (Vivactil) Quinidine (Quinidex, Quinaglute, Cardioquin, other names) Quinine (Quinamm) Sulfonamide antibiotics (Bactrim, Septra, Gantrisin, and others) Thioridiazine (Mellaril) Thiothixene (Navane) Tolbutamide (Tolinase) Tretinoin (Retin-A) Trifluroperazine (Stellazine) Vitamin A
6 Post IPL Treatment Instructions Patients should be instructed in post-treatment skin care and should be provided with written takehome instructions recommending they: Don t expose skin to UV light (sun exposure or the use of tanning beds) or self tan for at least 2 weeks. Don t shave for hrs after facial treatment. Don t use bleaching creams, or perfumed products for hrs. Don t pick or scratch the treated area. Avoid rough handling of the area treated. Leave any skin responses alone (they are temporary and will subside). Avoid very hot baths / showers / steam baths / sauna for 1 week. Avoid swimming in strong chlorinated water for 1 week. Avoid exfoliating or peels for 1 week. Avoid rough sports for hrs. Avoid wearing tight clothing. Keep the area clean and dry. Hydrate the body by drinking plenty of water/ Use sunscreen (min SPF 30+) and consider using protective cotton gloves for driving, a hat to protect facial areas. Immediately post-treatment, effective skin cooling of the epidermis can be helpful. The use of ice or cooling gel packs, aloe vera gel, etc., can improve patient comfort and reduce post-operative erythema.
7 Fitzpatrick Skin Classification Scale Skin Type Skin Color Characteristics 1 Caucasian Very light complexion Light eyes Freckles Usually blond or reddish hair color 2 Caucasian Light complexion Light eyes Occasional to frequent freckles Blond, reddish, light brown hair color 3 Darker Caucasian; light Asian Medium complexion Light to dark eyes Hair color usually brown to dark 4 Mediterranean; Asian; Hispanic Darker complexion Dark eyes Dark brown to black hair color 5 Middle Eastern; Latin American; light-skinned black; Indian Dark complexion Dark eyes Dark brown to black hair color 6 Dark-skinned black Black complexion Black eyes Black hair color Always burns; never tans Usually burns; tans with difficulty Sometimes mild burn; gradually tans Rarely burns; tans with ease Very rarely burns; tans very easily Never burns; tans very easily Visual representation of the Fitzpatrick Skin Classification Scale.
8 Skin Type Worksheet Patient's Name: Date: Score: What is the color of your eyes? LIGHT BLUE, GRAY OR GREEN BLUE, GRAY OR GREEN BLUE DARK BROWN BROWNISH BLACK What is the natural color of your hair? SANDY RED BLOND CHESTNUT, DARK BLOND DARK BROWN BLACK What is the color of your skin (unexposed areas) REDDISH VERY PALE PALE WITH BEIGE TINT LIGHT BROWN DARK BROWN Do you have Freckles on SUN exposed areas? MANY SEVERAL FEW INCIDENTAL NONE What happens when you stay in the sun too long? PAINFUL REDNESS, BLISTERING BLISTERING FOLLOWED BY PEELING BURNS SOMETIMES FOLLOWED BY PEELING RARELY BURNS NEVER HAD BURNS To what degree do you turn brown? HARDLY OR NOT AT ALL LIGHT COLOR TAN REASON-ABLE TAN TAN VERY EASILY TURN DARK BROWN QUICKLY Do you turn brown several hours after sun exposure? NEVER SELDOM SOMETIMES OFTEN ALWAYS How does your face respond to the sun? VERY SENSITIVE SENSITIVE NORMAL VERY RESISTANT NEVER HAD A PROBLEM When did you last expose yourself to the sun, tanning bed, or tanning creams? MORE THAN 3 MONTHS AGO 2-3 MONTHS AGO 1-2 MONTHS AGO LESS THAN 1 MONTH AGO LESS THAN 2 WEEKS AGO Do you expose the area to be treated to the sun? NEVER HARDLY EVER SOMETIMES OFTEN ALWAYS TOTAL SCORE: SCORE FITZPATRICK SKIN TYPE 0-7 I 8-16 II III IV OVER 30 V-VI
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