Motus AY Laser Consent

First name

Last name

Birthday

Day

Month

Year

I authorise 'The Elite Clinic Solihull ltd' to perform Laser treatments on my body

Treatment Requested

Hair Removal

Skin Rejuvenation

Vascular

Pigmentation

Lifestyle & Medical History (Please check the box if applies to you)

Does the Area have any of the following?

If checked any boxes specify

Taking any Medications/ supplements

Currently using/used any of the following in the last 6 months?

Please indicate how you skin would react in midday sun exposure with no sunscreen

Skin Type 1: Always burns, never tans

Skin Type 2: Easily burnt, eventually gets a moderate tan

Skin Type 3: Sometimes burns, quickly gets an average tan

Skin Type 4: Rarely burns, quick gets a deep tan

Skin Type 5: Very rarely burns, consistent tan

Skin Type 6: Never burns, consistent tan

Do you currently have a real/ fake tan

Have you ever used tanning injections/enhancers/Melanotan

When was your last UV exposure?

The information I have received is correct to the best of my knowledge, and I have not withheld any known medical state or condition. I will inform the Laser operator before treatment if there has been any change (for example medications taken)

I understand the results from this treatment vary considerable and a small percentage of people will not respond satisfactorily to treatment

I understand multiple treatments are necessary to achieve satisfactory results.

I understand there are no guarantee of permanent results and maintenance treatments may be necessary

I understand that i must avoid sun exposure on treated area for the duration of the treatment (and up to one month afterwards) or use a high sun protection to avoid sun damage.

I understand tanned skin cannot be treated, I understand treatment times are booked at specific durations between sessions. If unable to treat due to tanning this may impact results.

I understand that there may be short-term side effects such as: reddening, bruising, swelling, mild burning or blistering, hypo-pigmentation (lightening of the skin), or hyperpigmentation (darkening of the skin), as well as rare side effects such as scarring and permanent discolouration.

I understand that pigmented areas caused by sun damage may initially turn darker. This will be followed by "micro-crusting" of the lesion, after which it should flake away leaving an area without excessive pigmentation

I understand I must wear protective eye goggles to prevent damange from the laser.

I certify I have read and understood all the information. I understand that the treatment by the Motus AY Laser system involves payment, and the fee structure has been fully explained to me.

Photography Consent

I Do consent

I Do not consent

To photographs and other audio-visual and graphic materials before, during, and after the course of my therapy to be used for medical, marketing, and education purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.

I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. By signing this consent I agree to the terms of this agreement.

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Motus AY Laser Consent

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