Laser Skin Rejuvenation & Fractional CO2 Consultation Form

1. Treatment Requested

2. Medical Screening

PregnantTrying to become pregnantBreastfeedingDiabetesEpilepsy / seizuresAutoimmune diseaseImmune suppressionActive cancer or history of skin cancerHistory of keloid or hypertrophic scarringMelasmaVitiligoPsoriasis / eczema / dermatitisRosaceaCold sores / herpes simplex historyActive acne / infected lesionsOpen wound / broken skin in treatment areaRecent surgery in treatment areaSuspicious mole or changing skin lesionNone of the above

3. Medication & Topical Screening

Isotretinoin / Roaccutane in the last 12 monthsTopical retinoids / tretinoin / adapalenePhotosensitising medicationAntibiotics in the last 4 weeksSteroidsBlood thinnersHydroquinone or pigment treatment productsPrescription acne medicationNo relevant medication

4. Skin Assessment

5. Recent Procedures

Chemical peel in the last 4 weeksMicroneedling in the last 4 weeksIPL / laser in the last 6 weeksBotox in the last 2 weeksDermal filler in the last 4 weeksWaxing / threading / depilatory on area recentlyRecent exfoliation / acid peels / scrubsNo recent relevant procedures

6. Contraindications & Safety Acknowledgement

[acceptance* declaration-true]
I declare that the information I have provided is true and complete to the best of my knowledge.
[/acceptance]

[acceptance* lesion-declaration]
I understand that any suspicious lesion, mole, infection, rash, broken skin, or unusual pigmentation in the treatment area must be assessed before treatment, and treatment may be refused or postponed.
[/acceptance]

[acceptance* patch-clinical-assessment]
I understand that a clinical assessment and patch test may be required before treatment, and settings or treatment suitability may change on the day for safety reasons.
[/acceptance]

[acceptance* general-risk-consent]
I understand that laser skin rejuvenation and fractional CO2 may involve discomfort, redness, swelling, heat, peeling, flaking, dryness, prolonged erythema, acne flare, milia, bruising, blistering, burns, infection, pigmentation change, scarring, and unsatisfactory results.
[/acceptance]

[acceptance* co2-specific-consent]
I understand that Fractional CO2 Laser is a higher-downtime resurfacing treatment and may require stricter aftercare, sun avoidance, wound care, and a longer recovery period than standard rejuvenation treatments.
[/acceptance]

[acceptance* hsv-consent]
If I have a history of cold sores / HSV, I understand I must inform the clinic, as preventative medical advice or deferral may be necessary.
[/acceptance]

[acceptance* eye-protection]
I agree to wear appropriate protective eyewear and follow all operator safety instructions during treatment.
[/acceptance]

[acceptance* aftercare]
I agree to follow all pre-care and aftercare instructions, including sun protection, avoiding heat/sauna/exfoliation as directed, and contacting the clinic promptly if I experience an unexpected reaction.
[/acceptance]

[acceptance* result-acknowledgement]
I understand that multiple sessions may be required and results vary by skin type, indication, treatment intensity, healing response, and home care.
[/acceptance]

I consent to SMS reminders and promotional messages.