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Client Consent to Skin Rejuvenation Using MediPro12 IPL Mobile App

This Client Consent to Skin Rejuvenation Using MediPro12 IPL app is used by dermatology clinics to provide information on MediPro12 IPL treatments and to capture the patient's signature for consent. Also includes a treatment checklist for the therapist to complete before each treatment.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Client Consent to Skin Rejuvenation Using MediPro12 IPL Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Client Name

  • Ico textbox

    Phone

  • Ico multiline

    Client Address

  • Ico statictext

    I understand that the procedure is an elective cosmetic procedure and herby acknowledge the follo...

  • Ico statictext

    I understand that the extent of rejuvenation by the MediPro12 IPL varies from person to person a...

  • Ico textbox

    2. I would like the following area of my body to be treated

  • Ico decimal

    I understand that the cost of treatment will be $ (per session)

  • Ico statictext

    I understand that immediately following treatment (post) the area may appear reddened and there ...

  • Ico statictext

    I understand also that following the first treatment I may not see an immediate effect and will ...

  • Ico statictext

    I understand that there is a very slight possibility, following treatment, that depigmentation o...

  • Ico statictext

    6. I confirm that I have provided the clinic with any medical details, which may be relevant to m...

  • Ico statictext

    My signature below constitutes my acknowledgement that I have read, understand and fully agree to...

  • Ico signature

    Client Signature

  • Ico date

    Date

  • Ico signature

    Although my test results have been below average, I agree to the complete treatment with the Mega...

  • Ico date

    Date

  • Ico statictext

    Treatment Check List (Therapist MUST complete before each treatment)

  • Ico dropdown

    Does the client have any of the contra-indications?

  • Ico dropdown

    If the Client has gained a tan, was it within the last 4 weeks?

  • Ico dropdown

    Does the Client have any skin abnormalities which may be of concern?

  • Ico dropdown

    If the Client has received previous treatments, have they had any problems?

  • Ico dropdown

    Are you UNCERTAIN of the parameters required to treat the client?

  • ...and More!

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