Laser Patch Test Consent | Melatone Skin Clinic, Battersea

1

Your details

We need these to identify your record and to contact you if anything on this form needs a conversation first.

First name *

Last name *

Date of birth *

Mobile number *

Email * Which area are we patch testing?

Please complete every field marked with a star, and check your email address is correct.

2

Your skin tone

Think about how your skin reacts to strong sun with no sun cream. This is your Fitzpatrick type. Your clinician will confirm it on the day, so an honest best guess is fine.

Type I, very fairAlways burns, never tans Type II, fairUsually burns, tans a little Type III, mediumSometimes burns, tans well Type IV, olive or light brownRarely burns, tans easily Type V, brownVery rarely burns, deeply tans Type VI, deep brown to blackNever burns, deeply pigmented I am not sureYour clinician will confirm this with you

Please choose one option.

3

The last few weeks

Recent sun and recent hair removal both change how your skin responds to laser, so these two answers matter more than most.

In the last 4 weeks, have you had significant sun exposure, used a sunbed, or applied fake tan or gradual tanning products to the area? *

Yes No

In the last 6 weeks, have you waxed, threaded, plucked, epilated, or used hair removal cream on the area? *

Yes No, shaving only

Please answer both questions.

4

Medication and skincare

Tick everything that applies. Several of these make skin more light sensitive, which changes the settings we use or means we wait.

Roaccutane or oral isotretinoinNow, or at any point in the last 6 months Doxycycline, tetracycline or another antibiotic St John's Wort Retinoid or acid skincare on the treatment areaRetinol, tretinoin, glycolic, salicylic and similar A medicine my prescriber said increases sun sensitivity Steroids, taken by mouth or by injection None of the above

Please tick at least one option, or tick "None of the above".

5

Your skin history

Tick everything that applies. None of these automatically rules laser out. They tell your clinician how cautiously to start.

Keloid or raised scarring Dark marks that linger after spots, cuts or shaving Melasma Vitiligo Cold sores in or near the treatment area Eczema or psoriasis in the treatment area Active infection, open skin, or a new or changing mole in the area Tattoos or permanent makeup on the area None of the above

Please tick at least one option, or tick "None of the above".

6

General health

Tick everything that applies.

Pregnant, or I think I may be Breastfeeding Epilepsy A pacemaker or an implanted electronic device Diabetes An autoimmune or light sensitive condition such as lupus Cancer treatment now, or in the last 12 months Metal implants or metalwork under the treatment area None of the above

Please tick at least one option, or tick "None of the above".

7

Previous laser or IPL

Have you had laser or IPL hair removal before? *

Yes No, this is my first time

Anything else we should know?

Please answer this question.

8

What a patch test is, and what it can and cannot tell us

A patch test is a small trial on the area we plan to treat. Your clinician fires a few shots at different settings, then watches how your skin absorbs the energy. That is how your wavelength and settings get chosen, from what your skin actually does rather than from an assumption about your skin tone.

A normal reaction can include redness, warmth, mild swelling around the hair follicles, and a temporary change in skin tone. This usually settles.

Less common effects include blistering, crusting, lasting lightening or darkening of the skin, changes in hair texture, and scarring. Your clinician will talk you through the risks that apply to your skin type before anything is switched on.

What a patch test cannot do is rule out every reaction. Skin can respond differently over a larger area, or on a different day, or after a change in your medication, sun exposure or health. That is why we ask you to tell us if anything changes before your first full session.

Your patch test is £10, and we review the area with you before your first full session. We do not start a laser course without one.

For the full explanation, including what a normal reaction looks like on Fitzpatrick I to III skin and on Fitzpatrick IV to VI skin, and the signs that mean call us, read your laser patch test, explained.

Your laser is delivered by Catia Zaki, VTCT Level 4 laser clinician, under the clinical supervision of Arman Zaki, GMC-registered Physician Associate. If anything on this form needs a conversation first, we will call you before your appointment rather than let you travel in.

9

Your declaration

I have read the information above and had the chance to ask questions.I understand what a patch test is, what a normal reaction looks like, and that less common effects include blistering, lasting change in skin colour, and scarring. The information I have given is true and complete to the best of my knowledge.I will tell my clinician if anything changes before my first full session. I will follow the aftercare I am given and watch the test area.I will contact the clinic on 020 3576 7373 or hello@melatoneskinclinic.co.uk if I develop blistering, spreading redness, pain, or any reaction that is not settling. I consent to a laser patch test.I understand I can withdraw my consent at any time, including on the day, and that my clinician will confirm this consent with me in person before anything is switched on.

Please tick all four boxes. If you cannot agree to one of them, leave it unticked and call us on 020 3576 7373 instead.

10

Sign here

Sign with your finger on a phone or tablet, or with your mouse or trackpad on a computer.

Type your full name to confirm *

Please sign in the panel and type your full name.

11

How we hold your information

MELATONE SKIN CLINIC LTD, company number 16794829, Unit 13A, Battersea Business Centre, 99 to 109 Lavender Hill, London SW11 5QL, is the controller for this information.

We use it to assess whether laser is appropriate for you and to set your treatment safely. Our lawful bases are UK GDPR Article 6(1)(b), performance of a contract, and Article 9(2)(h), the provision of health care by a professional under a duty of confidentiality.

We keep your clinical record for 8 years after your last treatment, then securely destroy it. You can ask to see, correct, or restrict your information at any time by emailing hello@melatoneskinclinic.co.uk. You can also complain to the Information Commissioner's Office. Read our full privacy notice.

I understand how my health information will be used and stored. Optional. Email me skin advice and offers.You can unsubscribe at any time. Leaving this unticked does not affect your treatment.

Please confirm you understand how your health information is used.

Sending this form does not book your appointment. Book your patch test through our booking page, or message us on WhatsApp.

Your patch test consent form

Clinician use only, patch test record