M22 IPL Treatment Consent

Aesthetic clinics use this before performing intense pulsed light treatments with the M22 device. The patient accepts the treatment's risks and aftercare, chooses whether photos may be taken and answers a short medical history on medication, allergies and earlier procedures.

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In the Claude connectors directory

Page 1

Name

First Name

Last Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Date of birth

Phone number

I authorize the medical technician to perform treatments on me

I agree I do not agree

I understand that sun exposure or tanning goes against the pre- and post-care instructions and may raise the risk of complications

I agree I do not agree

Page 4

Taking aspirin or anticoagulants?

Yes No

Do you bruise easily?

Yes No

Any known allergies?

Yes No

If yes, please list your allergies

Patient final statement

Patient name (print)

Patient signature

Sign here

Date

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M22 IPL Treatment Consent

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