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.

Please complete all required fields and ensure all consent checkboxes are ticked before submitting.

Treatment Selection — Today's Booking

Tick all services you are booking or consenting to today:

LED / Photobiomodulation (PBM) CIT Microneedling IPL Skin Rejuvenation SHR Hair Removal Dream Facial (Microderm / LED) Facial Skin Analysis

Please select at least one treatment.

Client Information

First Name *

Last Name *

Preferred Name (optional)

Date of Birth *

Age

Occupation (optional)

Gender

Female Male Non-binary Prefer not to say Self-describe

Gender self-describe

Street Address *

Suburb

State

Post Code

Email *

Mobile *

How did you hear about us?

Referring Practitioner (if any)

Treatment Goals & Concerns

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

Skin appearance / texture Acne or breakouts Fine lines & wrinkles Rosacea / redness Body pain or inflammation Joint / muscle recovery Sleep or mood support Energy & general wellness Hair / scalp Pigmentation / sun damage Unwanted facial or body hair Other

Treatment area(s) requested

Current pain level (0 = none, 10 = severe)

0 1 2 3 4 5 6 7 8 9 10

Inflammation level

Low Moderate High

Energy level

Low Moderate High

If there was something you could change or improve, what would it be?

Skin history (tick all that apply):

Dry Oily Combination Discolouration Acne scarring Uneven texture Fine lines & wrinkles Enlarged pores Sun damage Rosacea Acne / breakouts Dark under-eye circles Sensitive / reactive Eczema / dermatitis Other

Other skin notes

Emergency Contact

Emergency Contact Full Name

Relationship

Emergency Contact Phone

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):

Pregnant or trying to conceive Breastfeeding / nursing Diabetes (Type 1 / Type 2) High or uncontrolled blood pressure Heart disease Pacemaker / implanted electronic device Epilepsy or seizure disorder Photosensitive condition (e.g. lupus, porphyria) Active or recent cancer Current oncology treatment / chemo / radiation Thyroid disease or thyroid medication Autoimmune disease Skin allergies / contact dermatitis Asthma / respiratory condition Eye disease, retinal disorder, glaucoma Recent eye surgery Active infection / fever / contagious skin condition Recent surgery / laser / peel / injectable / tattoo or burn on area Impaired sensation / neuropathy Heat intolerance / difficulty signalling discomfort Mental health condition affecting consent capacity Other (specify below)

Known allergies

Recent surgeries / treatments / procedures (last 6 months)

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.

I am currently taking a medication, supplement or topical agent that may cause light or photo-sensitivity.

Please list relevant medications, supplements and topical agents

Other medical concerns or relevant history

Previous Treatment History

LED / Photobiomodulation (PBM)

None Some Regular user

CIT Microneedling

None Some Regular user

IPL Skin Rejuvenation

None Some Regular user

SHR Hair Removal

None Some Regular user

Dream Facial / Microdermabrasion

None Some Regular user

Facial Skin Analysis

None First time

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.

Possible Side Effects

Warmth, transient redness or flushing, dryness, mild irritation, headache, eye discomfort if protective eyewear is removed, fatigue or dizziness, or a short-lived flare of symptoms before improvement.

IF YOU FEEL UNCOMFORTABLE — SPEAK UP Tell staff immediately if you feel unwell, experience pain, visual disturbance, skin reaction or any other concerning symptom.

LED / PBM consent notes or questions

Photo Consent

Please tick any permissions you wish to provide:

Before photos for treatment records After photos for treatment records De-identified before and after images for education or marketing I do not consent to photography

Fitzpatrick Skin Type (for IPL & SHR)

For IPL and SHR treatments, please select your Fitzpatrick skin type.

Type I — Very fair, always burns, never tans Type II — Fair, usually burns, sometimes tans Type III — Medium, sometimes burns, always tans Type IV — Olive, rarely burns, tans easily Type V — Brown, very rarely burns, tans very easily — NOT suitable for IPL/SHR Type VI — Dark brown / black, never burns — NOT suitable for IPL/SHR

Acknowledgements & Consent *

Please read each statement carefully and tick to confirm your agreement. All boxes marked with * must be completed before submission.

The information I have provided is accurate and complete to the best of my knowledge. *

I have had the opportunity to ask questions, and the risks, benefits and reasonable alternatives have been explained to me in plain language. *

I understand each treatment is not a substitute for medical diagnosis or treatment, and I will seek qualified medical advice for any medical concern. *

I agree to follow all practitioner instructions, including protective eyewear requirements where applicable. *

I understand aftercare is important and I agree to follow the aftercare guidance provided. *

I understand I may withdraw consent at any time before or during treatment. *

I confirm that I am 18 years of age or older, or I am completing this form with a parent/guardian who is providing consent on my behalf. *

Digital signature — full name *

Signature date *

Parent / guardian name (if under 18)

Parent / guardian relationship (if under 18)