Patient Intake — Strictly Confidential

Multi-Service Consent & Screening Form

Comprehensive Intake Form — Version 2.0 · May 2026

Thank you for choosing LEREDD Light Therapy. Please complete this form in full before your first appointment. Your responses help us assess suitability, screen for contraindications, and document your informed consent. If anything is unclear, please call us on 0480 839 388 before submitting.

01

Treatment Selection — Today's Booking

Tick all services you are booking or consenting to today:

Please select at least one treatment.
02

Client Information

03

Treatment Goals & Concerns

Primary reasons for seeking treatment (tick all that apply):

Skin history (tick all that apply):

04

Emergency Contact

05

Medical Screening

Important — Please Read Tick anything that currently applies. Non-disclosure may invalidate this consent and increase your risk of an adverse reaction.

Current medical conditions (tick all that apply):

Photo-sensitising Medications — Please Read Some prescription and over-the-counter medications, supplements and topical agents can increase light sensitivity or interact with photobiomodulation and IPL treatments. Examples (not exhaustive) include isotretinoin and other retinoids, tetracycline/doxycycline and fluoroquinolone antibiotics, some NSAIDs and diuretics, lithium, certain antidepressants and antipsychotics, St John's wort, immunosuppressants, chemotherapy or radiation-sensitising medicines, and photodynamic agents.
06

Previous Treatment History

For each treatment, select your experience level and note any previous reactions.

LED / Photobiomodulation (PBM)

CIT Microneedling

IPL Skin Rejuvenation

SHR Hair Removal

Dream Facial / Microdermabrasion

Facial Skin Analysis

07

LED Light Therapy & PBM — Information & Consent

About This Treatment

LED light therapy (PBM) uses non-ionising visible red and/or near-infrared light. It is not UV light and not a tanning treatment. At LEREDD it supports general wellness, skin appearance, and body comfort. Individual outcomes vary and multiple sessions may be required.

Possible Side Effects

Warmth, transient redness or flushing, dryness, mild irritation, headache, eye discomfort if protective eyewear is removed, fatigue or dizziness, a short-lived flare of symptoms before improvement, or rarely a photosensitive reaction.
IF YOU FEEL UNCOMFORTABLE — SPEAK UP Tell staff immediately if you feel unwell, experience pain, visual disturbance, skin reaction or any other concerning symptom. Treatment will be paused.

Contraindications

  • 01Photosensitivity — photosensitive medical condition or photosensitising medication
  • 02Cancer & oncology — active cancer, suspected malignancy, current/recent oncology treatment. Written clearance required.
  • 03Pregnancy & breastfeeding — disclose; treatment over abdomen/pelvis/breast avoided without clearance
  • 04Epilepsy — seizure disorder or sensitivity to flashing light
  • 05Eyes & vision — eye disease, retinal disorder, glaucoma, recent eye surgery, refusal to wear protective eyewear
  • 06Skin & wound integrity — active infection, open wounds, recent burns, laser, peel, injectable, surgery or tattoo on area
  • 07Cardiac, vascular & metabolic — pacemaker, serious cardiac condition, uncontrolled hypertension/diabetes, neuropathy, heat intolerance
  • 08Thyroid — thyroid disease or treatment directly over thyroid area
  • 09Under 18 — parent/guardian consent required
08

CIT Microneedling — Information

About This Treatment

CIT (Collagen Induction Therapy) uses fine needles to create controlled micro-channels in the skin, stimulating collagen and elastin production to improve texture, scarring, fine lines, and skin quality.
Treatment Options: Face (60 min)  |  Face & Neck (75 min)  |  Face, Neck & Décolletage (90 min)

Expected Outcomes

Improved tone and texture, reduction in scars and pitting, diminished fine lines, enhanced plumpness. A series of 3–12 treatments recommended.

Post-Care

Expect mild to moderate redness, flaking, swelling and sensitivity for 12–48 hours. Avoid sun exposure and heat. Skin may feel dry and tight for 3–5 days.

Contraindications

  • 01Active skin infections / open wounds
  • 02Photosensitive conditions or medications — isotretinoin requires 6-month washout
  • 03Pregnancy
  • 04Blood-thinning medications or clotting disorders
  • 05Recent procedures on treatment area
  • 06Active acne or rosacea flare
  • 07Known keloid scarring tendency
  • 08Under 18
09

IPL Skin Rejuvenation — Information

About This Treatment

IPL uses precise pulses of broad-spectrum light to target pigmentation, sun damage, redness, and visible capillaries.
Treatment Options: Vascular Spot (30 min)  |  Hands (25 min)  |  Full Face & Neck (60 min)  |  Chest (45 min).
Initial Consult & Skin Patch Test required (30 min).

Post-Care

Avoid sun exposure for 14 days post-treatment. Apply broad-spectrum SPF daily. Avoid heat for a few days. Avoid strenuous exercise for 72 hours.

Contraindications

  • 01Active tan or recent sun exposure
  • 02Photosensitive conditions or medications
  • 03Fitzpatrick skin types 5 and 6 — NOT suitable
  • 04Active skin infections, open wounds or herpes simplex
  • 05Pregnancy
  • 06History of keloid scarring
  • 07Pacemaker or implanted electronic device
  • 08Recent injectables, laser or chemical peel on treatment area
  • 09Under 18
10

SHR Hair Removal — Information

About This Treatment

SHR uses advanced IPL technology to gradually reduce unwanted hair growth. Superior hair reduction vs Nd:YAG.
Treatment Options: Lip & Chin (20 min)  |  Underarms (30 min)  |  Chest (30 min)  |  Back (35 min)  |  Full Legs (45 min).
Initial Consult & Skin Patch Test required (30 min).

Post-Care

Keep treated area cool. Avoid tight clothing 24 hrs. Apply SPF daily. Avoid heat treatments for 24 hrs.

Contraindications

  • 01Recent sun exposure or active tan
  • 02Very light, grey, blonde or red hair
  • 03Fitzpatrick skin types 5 and 6 — NOT suitable
  • 04Photosensitive conditions or medications
  • 05Active skin infections or open wounds
  • 06Pacemaker or implanted electrical device
  • 07Pregnancy
  • 08Hormonal conditions affecting hair growth (e.g. PCOS)
  • 09Under 18
11

Dream Facials (Microdermabrasion / LED) — Information

About This Treatment

Revive & Glow Dream Facials combine gentle microdermabrasion, LED light therapy, lymphatic massage, and targeted skincare.
Treatment Options: Revive & Glow LED Express (30 min)  |  Revive & Glow Microderm LED (60 min)

Post-Care

Keep skin hydrated. Avoid harsh exfoliants. Apply SPF daily. Avoid hot showers/saunas/exercise same day.

Contraindications

  • 01Active skin infections or open wounds
  • 02Severe skin conditions (eczema flare, psoriasis, severe rosacea)
  • 03Photosensitising treatments or medications
  • 04Recent laser or chemical peel
  • 05Pregnancy or breastfeeding
  • 06Very sensitive or reactive skin
  • 07Under 18
12

Facial Skin Analysis — Information

About This Service

Our advanced imaging reveals early pigmentation, redness, dehydration, and congestion. Results design your personalised treatment plan. Includes: Before & After comparison, skin age assessment, RGB/UV/sensitivity/pore analysis, skin typing, and emailed results.

Contraindications

  • 01Heavy makeup, self-tanning products or tinted moisturisers — arrive with clean face
  • 02Active skin infections or open wounds
  • 03Recent laser or chemical peels — wait 5–7 days
  • 04Photosensitive skin conditions
13

Fitzpatrick Skin Type (for IPL & SHR)

For IPL and SHR treatments, please select your Fitzpatrick skin type. Your practitioner will confirm during your patch test.

14

Acknowledgements & Consent

Please read each statement carefully and tick to confirm your agreement. All boxes must be ticked to submit.

15

Privacy & Health Information Notice

Collection of Personal and Health Information

LEREDD Light Therapy (ABN available on request) collects your personal and health information for the purpose of providing safe, appropriate and individualised aesthetic and wellness services. Collection is authorised under the Privacy Act 1988 (Cth) and, where applicable, the Health Records Act 2001 (Vic).

Why We Collect Your Information

We collect your name, contact details, date of birth, health history, medications, and treatment records to: assess your suitability for each treatment; screen for contraindications and safety risks; provide and document your care; communicate with you about appointments and aftercare; and meet our legal, insurance and regulatory obligations.

How We Store and Protect Your Information

Your records are stored securely in our clinic management system. Access is restricted to authorised staff only. We do not sell or share your personal information with third parties except where required by law, with your explicit consent, or as necessary to provide your care (e.g. referral to another practitioner).

Disclosure to Third Parties

We may disclose your information to: your nominated emergency contact; healthcare practitioners involved in your care; our professional insurance provider; or regulatory and law-enforcement bodies where required by law.

Your Rights

You have the right to access the personal information we hold about you and to request corrections if it is inaccurate, incomplete or out of date. To make a request, please contact us in writing at the clinic address or via contact@leredd.com. We will respond within 30 days.

Sensitive Health Information

Health information is classified as sensitive information under Australian privacy law. We handle it with the highest degree of care and will only use it for the purposes described in this notice or with your express consent.

Retention

Client health records are retained for a minimum of seven (7) years from the date of last service, or until you reach the age of 25 years (whichever is later), in accordance with Victorian health record requirements.

Complaints

If you have a concern about how we handle your information, please contact us at contact@leredd.com. If you remain unsatisfied, you may lodge a complaint with the Office of the Australian Information Commissioner (OAIC) at www.oaic.gov.au.

Contact

LEREDD Light Therapy · Bentleigh, VIC · Phone: 0480 839 388 · Email: contact@leredd.com

16

Photography & Image Consent (Optional)

Image consent is optional and is not required to receive treatment. You may refuse without affecting your care.
17

Disclaimer & Business Terms

No Medical Advice. The treatments and services provided by LEREDD Light Therapy are aesthetic and general wellness services. They are not medical procedures, do not constitute medical advice, and are not a substitute for professional medical diagnosis, treatment or care. If you have a medical condition, concern or query, please consult a qualified medical practitioner before attending.

Individual Results. Results from treatments vary between individuals. LEREDD makes no guarantee of specific outcomes. Factors including skin type, health status, lifestyle, adherence to aftercare, and number of sessions will influence your results. Photography shown in marketing materials represents individual cases and may not reflect your outcome.

Scope of Practice. Our practitioners are trained in the aesthetic and wellness treatments listed in this form. They are not medical practitioners. Any health information discussed during your visit is for treatment safety purposes only and does not constitute a medical consultation or diagnosis.

Right to Decline Treatment. LEREDD reserves the right to decline, postpone or modify treatment where a practitioner reasonably believes it would not be safe or appropriate to proceed, including on the basis of information disclosed on this form or observed during consultation.

Cancellation Policy. We require a minimum of 24 hours' notice to reschedule or cancel an appointment. Late cancellations or no-shows may incur a fee at our discretion. Please contact us as soon as possible if your circumstances change.

Adverse Reactions. While we take every precaution to ensure your safety, adverse reactions can occur. You agree to contact LEREDD promptly if you experience any unexpected symptom or reaction following treatment. LEREDD will work with you to address any concern in a timely and professional manner.

Governing Law. These terms and this consent form are governed by the laws of the State of Victoria and the Commonwealth of Australia. Any dispute arising from your treatment at LEREDD will be subject to the jurisdiction of Victorian courts.

Updates to This Form. LEREDD may update this consent form from time to time. You will be asked to re-complete an updated form when material changes are made. Version 2.0 — May 2026.

18

Declaration & Digital Signature

By typing your full name below and submitting this form, you confirm that all information provided is accurate and that you have read, understood and agree to all sections of this consent form. This constitutes your electronic signature under Australian law.

If completing on behalf of a person under 18: