Consultation Form

Please fill out the form below before your appointment

Your Details

Client name

Date of birth

Day

Month

Year

Address

Town/City

County

Postcode

Contact Number

Emergency Contact Name

Emergency Contact Number

How did you hear about me? If referred, by who?

Medical History

Are you currently under the care of a physician?

If any of the below are marked yes, please go into more detail at the bottom of the list.

Heart conditions/pacemaker

Yes

Severe circulatory disorders/DVT

Yes

Diabetes

Yes

Skin disorders

Yes

Kidney problems

Yes

Swelling/oedema

Yes

Haemophilia

Yes

Cancer (including skin cancer)

Yes

Limitation of movement/arthritis

Yes

Prone to keloid scarring

Yes

Epilepsy or seizures

Yes

Stroke

Yes

Hormone imbalance

Yes

Hepatitis

Yes

Claustrophobia

Yes

Recent scar tissue/surgery

Yes

Metal plates/pins/piercings

Yes

Allergies

Yes

Respiratory problems

Yes

Lupus Erythematosus

Yes

High/low blood pressure

Yes

Hypomelanism (Albinism)

Yes

Porphyria

Yes

Light Induced Headaches

Yes

Photosensitive Eczema

Yes

Eye disease

Yes

Operations within 6 months

Yes

Are you pregnant

Yes

If you answered yes to any of the above, please supply additional information

Any other medical conditions/ailments yes/no

Yes

If yes, please specify

Are you taking or applying topically any prescribed medication including the Contraceptive Pill/HRT? Certain medications can induce photosensitivity and may be contra-indicated for the Dermalux treatment.

Are you taking any non-prescription medication including Vitamin supplements, St Johns Wort, Prebiotics etc?

Do you have a history of regular or long-term antibiotic use?

Yes

Declaration

I confirm that I have answered all the questions to the best of my knowledge and understand that withholding necessary information about my health and medication may increase my risk of possible side effects.
I will inform my practitioner before every treatment if there has been any change to my circumstances or medication I may be taking.
I understand that the Dermalux systems have not been tested on pregnant women and therefore the risk to the foetus or pregnant woman is unknown.
I understand the benefits and likely clinical outcome of the Dermalux treatment and that multiple treatments are necessary to achieve optimal results.
I acknowledge that no written or implied verbal guarantee, warranty or assurance has been made to me regarding the outcome of the procedure.
I agree that I have read and understood all the information provided. My questions have been answered satisfactorily and I have made an informed decision to receive the Dermalux treatment.

I declare that the info I’ve provided is accurate and complete.

Client signature (name)