L Aesthetics
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Laser Hair Removal Consent Form
Patient Info
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
D.O.B
(Required)
DD slash MM slash YYYY
Questions
Skin Type
(Required)
Very Fair – always burns/never tans (I)
Light Skin – always burns (I-II)
Light to slight olive tone – sometimes burns, tans minimally (II)
Light to more olive tone – sometimes burns, slowly tans to light brown (II-III)
Olive light – Rarely burns, slowly tans to light brown (III)
Olive medium – Rarely burns, always tans to moderate brown (III-IV)
Olive dark – Rarely burns, always tans (IV)
Darker tone – Never burns, tans, moderately pigmented (V)
Very Dark – Never burns, deeply pigmented (VI)
Patient Consent
I UNDERSTAND THAT IN RELATION TO LASER HAIR REMOVAL:
(Required)
● Hair removal, whist permanent, is variable and results may vary. Most clients require a minimum of 10 treatments
● The treatment is most successful on clients with fair skin and dark hair
● Course hair responds better to treatment than fine hair,
light blonde, grey/white and red hair does not respond to treatment
● Facial hair takes longer to respond to treatment
● Clients with darker skin, who are treated at lower fluence will require additional treatments
● No guarantee has been made regarding growth of dominant follicles that may be triggered by hormonal changes, stress, illness, pregnancy and/ or other causes
● Regardless of precautions taken, I acknowledged that adverse effects may occur
I understand
IN RELATION TO MY INITIAL & SUBSEQUENT TREATMENTS, I ADVISE THAT:
(Required)
● I do not suffer from epilepsy
● I am not tanned from any source, including sun exposure, fake tans and tanning salons
● I have not received melatonin injections within the last six months
● I do not have a history of cold sores or herpes in the area being treated
● I do not have a history of abnormal/keloid scarring
● I have not taken the drug Roaccutane in the last four weeks
● I have not used Retin-A in the past two weeks in the area being treated
● I will wear the protective eyewear provided whilst the laser is being operated
● I do not have any blood borne diseases such as HIV, hepatitis C, etc
I understand
I WILL ADVISE L AESTHETICS IF ANY OF THE ABOVE CHANGES
(Required)
Regardless of precautions taken, I acknowledge the possibility of an adverse reaction to laser and accept sole responsibility for any medical care that may become necessary.
DO NOT SIGN THIS FORM UNTIL YOU HAVE READ & UNDERSTOOD THE CONTENTS & ALL YOUR QUESTIONS HAVE BEEN SATISFACTORILY ANSWERED.
If 18 years and younger a parent/guardian must be present for consultation, your first treatment (optional) and sign a consent form.
I acknowledge the possibility of an adverse reaction to laser and accept sole responsibility for any medical care that may become necessary.
Name
(Required)
First
Last
Date
DD slash MM slash YYYY
Signature
(Required)
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