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CONSULTATION FORM  LASER ROSACEA TREATMENT

Birthday
Day
Month
Year
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Do you get regular cold sores?
Yes
No
Have you ever had skin cancer?
Yes
No
Do you have any keloid scars?
Yes
No
Have you ever had vitiligo?
Yes
No
Have you ever taken Roaccutane?
Yes
No
Have you ever taken St Johns Wart?
Yes
No
Do you have any allergies?
Yes
No
Do you suffer with Polycystic Ovarian Syndrome?
Yes
No
Do you have any thyroid conditions?
Yes
No
Have you had any past major / minor operations?
Yes
No
Do you have a pacemaker?
Yes
No
Do you have diabetes?
Yes
No
Do you have any form of Epilepsy?
Yes
No
Do you have any immune deficiencies? Lupus?
Yes
No
Do you use Retin A or Retinol?
Yes
No
Do you have any warts, Verrucae or nail fungal infections?
Yes
No
Have you had recently had any sun exposure, sun beds or applied false tan?
Yes
No

I hereby authorise Goda Geguze to treat me using the Ellipse system for Rosacea. I understand that multiple treatments are necessary based on the unique skin needs and condition. I also understand that the treatment using Selective Waveband Technology may need to be performed in repeated sessions in the future to obtain optimal results.

Goda Geguze have informed me about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have. I understand that there are certain risks associated with Selective Waveband Technology treatment and they include but are not limited to:

• Redness, localised swelling and mild tenderness,

• Although rare, adverse effects such as light burns, blister and bruises may occur.

• On occasion SWT treatment may cause temporary pigmentation changes to the skin.


I agree to follow the post treatment recommendations advised by Goda Geguze in order to ensure the best possible results. I understand that excessive heat should be avoided for 48 hours and that exposure to the sun, sun bed and fake tan must be avoided for 30 days before treatment and 30 days after treatment, also a sun block of SPF 30+ must be used on the exposed skin areas. Otherwise it is possible that blotchy skin pigmentation, hyper- or hypo-pigmentation might occur. I agree to co-operate with the recommendations of Goda Geguze while I am under their care, realising that any lack of co-operation could result in less than optimum results. I also agree to inform the clinic above immediately should any adverse skin reactions occur.

I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure.

 for the above mentioned services and understand that there will be no refunds for any performed services.

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TO BE COMPLETED BY THE PRACTICIONER

HR - Hair Reduction PL - Pigmented Lesions FTV - Facial Thread Vein DF - Diffuse Redness C - Collagen Boost AC - Acne LV – Leg Vessel

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