IPL Patient Screening Form

First Name

Last Name

Phone

Please answer honestly. Certain conditions or medications make IPL unsafe.

Have you used any of the following in the last 4 weeks?

Accutane (Isotretinoin)

Retin-A, Tretinoin, or heavy-duty retinol products

Antibiotics (specifically tetracyclines)

St. John’s Wort or other photosensitizing supplements

Sun Exposure: Have you had any unprotected sun exposure, used a tanning bed, or applied self-tanning lotion within the last 4 weeks?

Yes

Medical History:

History of keloid scarring or abnormal wound healing?

History of photosensitive epilepsy (flashing lights trigger seizures)?

Pregnancy or breastfeeding?

Do you have a pacemaker or internal defibrillator?

Check all areas you wish to address during this treatment cycle.
Please answer the following based on your selected goals:

Core Concerns:

Hair Removal (Add Info Below)

Pigmentation: (Freckles, age spots, sun damage)

Vascular: (Spider veins, broken capillaries, rosacea)

Active Acne: (Redness, inflammation)

Texture/Tone: (Skin rejuvenation, fine lines, dullness)

Laxity: (Skin lifting and tightening)

Hair Removal (Specify Areas:

Please circle or describe your skin type using the Fitzpatrick Scale (I-VI):

I (Always burns, never tans) | II | III | IV | V | VI (Deeply pigmented, rarely burns)

Please answer the following based on your selected goals:

For Hair Removal: Have you waxed, plucked, or used epilators on the area in the last 3 weeks? (We need the root intact).

For Spider Veins/Vascular: Are you currently taking blood thinners or aspirin?

For Acne: Are you currently under the care of a dermatologist for this condition?

For Skin Lifting/Rejuvenation: Please rate your priority level (1–5) for improving skin firmness versus surface texture.

IPL is a series-based treatment. To achieve results, patients must acknowledge:

I understand that multiple sessions (typically 3–6) are required for optimal results.

I understand that "skin lifting" refers to collagen stimulation and tightening, not surgical-grade lifting.

I agree to strictly avoid direct sun exposure and use SPF 30+ daily for the duration of the treatment series.

Sammies Beauty Shop