Laser Hair Removal Consultation Form

Laser Hair Removal Consultation
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Email
example@example.com
Profession
How did you hear about us?
Area/s to be treated and expectations

Lifestyle
Current Skin Care Regime/Products
Skin Type - fair, med, dark
Hair Removal Methods previously
How Frequently
Do you have any known hormone imbalances?
Hair, skin & eye colour
How well do you tan? Do you burn?
How well do you hold a tan?
Do your parents have lighter or darker skin than you?

Medical
Are you taking any medication?
(In particular photosensitizing medications e.g St Johns Wort, Roaccutane)
Do you have any allergies?
Are you pregnant or have previously been?
Are you currently receiving any medical treatment?
Have you had any recent operations/scar tissue?
Do you have any tumors, abnormal swelling or lymph oedema?
Do you have any heart/cardiac disorders?
Do you have Thrombosis/Phlebitis (blood clots)?
Do you have a Pacemaker or internal metal pins?
Do you have a personal or family history of skin cancer?
Do you have epilepsy?
Do you have Diabetes?
Recent exposure to UV Lights (eg sunbeds)
Recent use of self tanning/skin colouring products
History of Keloid (Raised) scarring
Fragile or exceptionally dry skin
Do you suffer from Herpes Simplex 2 (cold sores)?
Have you recently had Botox/Collagen/Injectables?
Do you take any form of contraception/hormonal substitutive?
Do you have tattoos/semi permanent makeup?
Do you have a Thyroid Problem?
Do you have any skin disorders?
Psoriasis Dermatitis or Vitiligo, Pigmentation, eczema (in treatment area)
Signature

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I confirm that I have received a full Consultation with regards to the proposed laser hair removal treatment and would agree that it has been explained to me fully. I am aware of the possible side effects and agree to follow both the pre and post care to minimise the risk of any adverse reaction.

I agree to advice Eve & Adam Beauty Clinic of any changes in personal medical circumstances before each treatment.

I understand that after treatment, there will be heat in the area and there may be some redness. In rare cases oedema and blistering can occur. This is a normal side effect of treatment and will settle within days. Instructions have been given regarding aftercare and advice and I agree to follow these instructions and to inform Eve & Adam Beauty Clinic of any condition that causes concern immediately.

I understand that I will require more than one treatment to achieve the desired results and am aware that in some very rare cases hair reduction may not occur at all. I also am aware that I need to be consistant with the treatments ie, follow the correct number of weeks between each one as adviced by the Therapist, as allowing too much time between may not achieve the desired response.

This has been fully explained to me and I am aware the results of the treatment may vary.

I understand the need to advise the staff of any changes to medication or any sun exposure, sun bed use or tanning products used between treatments.

I have been advised to shave hair in the weeks between treatment and that waxing or plucking hairs will result in a prolonged treatment plan.

I hereby certify that I have been fully informed of the nature of the procedure, expected outcome and possible complications. I understand that there can be no guarantee or assurance as to the final result that may be obtained.

I consent to the taking of photographed if discussed, and authorize their anonymous use for the purpose of medical audit, education and promotion. I am aware that my condition is primarily of cosmetic concern and that the decision to proceed is based solely on my express wish to do so.

I have been given the opportunity to ask questions and hereby certify that I have read and fully understand the contents of this consent form and the information I have provided is correct.
Signature

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Laser Hair Removal Consultation

Lifestyle

Medical