Templates · Free template · Light consent

IPL Photofacial Consent Form Template

A printable consent form for IPL treatments for pigmentation and redness, including the screening that matters and the expected darkening of spots clients should know about.

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Last reviewed September 2026 · Not legal advice

Tell clients what will look worse first

After IPL, sun spots often darken and then flake away over days. Clients who are not told that assume something has gone wrong. The form should describe the expected sequence and the timeline.

Screening should cover recent tanning, photosensitising medications, isotretinoin, and skin type, since these change or rule out treatment.

Clinic name · address · phone

IPL Photofacial Consent Form

Client

Full name

Date of birth

Phone

Screening

Tanning, sun exposure, or self-tanner in the past 4 weeks? Yes No

Photosensitising medication? Yes NoIf yes, details

Isotretinoin in the past 12 months? Yes No

Pregnant or breastfeeding? Yes No

History of keloid, cold sores, or melasma? Yes NoIf yes, details

Any suspicious or changing moles in the area? Yes No

Risks and acknowledgements

Initial each item to confirm you have read and understood it.

InitialsI understand pigmented spots may darken and flake over several days after treatment.

InitialsI understand risks include redness, swelling, blistering, pigment change, and burns.

InitialsI agree to avoid sun exposure and use SPF daily.

InitialsI understand that a series of treatments is usually needed.

InitialsI have disclosed all relevant medical history and medications.

Consent

I have had the chance to ask questions
I received aftercare instructions
I consent to treatment

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/ipl-photofacial-consent-form/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card required See how digital forms work →

See how Zdrovia is set up for laser clinics.

Frequently asked questions

Should skin lesions be checked first?

Yes. Suspicious lesions should be assessed by a physician before being treated with light.

Who can perform IPL?

Scope varies by province. Check your regulator.

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.