BLUE SKIN LASER CONSENT FORM

I agree to the following:

LATENESS & CANCELLATION POLICIES I do understand our lateness, cancellation, and rescheduling policy are as follows: Please arrive at least 5 minutes before your scheduled time. Delayed arrival will limit the time of your experience, reducing the effectiveness of your treatment and the expectations of your visit. In consideration of other guests, service time will not be extended for delayed arrivals. As we are by appointment only, kindly give 24 hours advanced notice from your scheduled appointment time to cancel or reschedule. Failure to provide such notice will result in a $30 fee for standard services or a $60 fee for full body services being charged upon your visit. If you do not agree to pay the fee your appointment will be count like you did the session from the date of your cancellation. more than 2 delete will be request your credit card for your next appt I duly authorize BLUE SKIN LASER to perform alma soprano ice laser form hair removal procedure , and any other measures, which in their opinion, may be necessary.I understand the blueskinlaser Lasers laser system is intended for hair removal and that clinical results may vary with different skin types, hair color, and body location. I understand there is a possibility of rare side effects, such as scarring and permanent discoloration; as well as short-term effects, including redness, mild burning, blistering, temporary bruising and discoloration of the skin, such as hypo pigmentation (decrease in skin pigment) or hyper pigmentation (increase in skin pigment). These effects have been fully explained to me.I understand that to achieve maximum results the protocol prescribed should be adhered to. The treatment schedule is designed to maximize the results during treatment of each hair cycle. If for any reason the schedule cannot be adhered to, I understand that the total percentage of hair loss could be affected. In addition, hair follicles that are dormant now may become active during or after my treatment program and additional treatments may be necessary. I also understand that I will have to pay for these additional treatments.

I have read and understand this agreement and all my questions have been addressed and answered to my satisfaction. I consent to the terms of this agreement.

Name

First NameLast Name

Date of Birth

Date

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

MEDICATIONS:

What oral medications are you presently taking?

Other

Are you on any mood altering or anti-depression medication?

If Yes, when did you last use it?

mm/dd/year

Have you ever used Accutane?*

If Yes, when did you last use it?

mm/dd/year

What topical medications or creams are you currently using?

Others (Please list):

Have you ever had laser hair removal?*

HISTORY

Have you used any of the following hair removal methods in the past four weeks IN THE AREAS THAT WILL BE LASERED?

Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*

Have you recently used any self-tanning lotions or treatments?*

Do you form thick or raised scars from cuts or burns?*

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*

Are you breastfeeding?*

Are you using contraception?*

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

Occupation

How were you referred to us?

Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*

If yes, for what:

Are you currently under the care of a dermatologist?*

If yes, for what:

Do you have any of the following medical conditions? (Please check all that apply)

Do you have any other health problems or medical conditions? If so, please list:

Please note any coupon deals:

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Parent or Guardian's Date of Birth*

Date

By submiting this form, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

Email

example@example.com

Consent Form