Studio 18
18 High St,
Sandy Bedfordshire SG19 1AQ

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Infrared Light Therapy-Consultation Form

First name

Last name

Phone

Birthday

Day

Month

Year

Address

This treatment is solely for your own use*

Current Medications

Allergies

Are you under investigation or waiting diagnosis?

Yes

If yes please provide details

Have you had any issues with cosmetic procedures in the past?

Have you had or do you suffer with any of the following conditions?

Diabetic with Microangiopathy

Autoimmune disease

Scleroderma

Hepatic

Acute infection & Chron infection risk

Severe adiposities (Per Magna BM1>30)

Hypersensitivity against ingredients

Severe kidney disease

Blood coagulation disease

Neuromuscular (i.e. MS, ALS, Motor neuropathy myasthenia gravis, or Lambert-Eaton syndrome

Skin conditions

Anaphylaxis

Do you have any active infection of the intended site of the procedure

Are you taking antibiotics

Will you contact Popsy Woo if you experience any side effects from your treatment?

Are you pregnant or breast feeding?

What treatment are you considering and what are your aims/motivations for having the procedure and the desired outcome? Please provide details here...

Consent: I can confirm that the information provided is accurate. I accept the risks and complications of the procedures. I consent to the procedure being carried out at Popsy Woo Aesthetics following face to face consultation.

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Date and time

Day

Month

Year

Time

:HoursMinutes