Laser Hair Removal Consent Form

Mode Beauty NYC

Laser Hair Removal Consent Form
Name *
Phone *
Birthdate*

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Address

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Email*
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How did you hear about Mode Beauty NYC?
How would you describe your skin? *

NormalDryOilyCombination
When were last exposed to the sun, including tanning booths? *
Do you use sunless tanning products? If yes, when was the last use? *
Do you experience hyper-pigmentation (darkening of the skin) or hypo-pigmentation (lightening of the skin) or marks after physical trauma?*

YesNo
Are you allergic to anything? *

YesNo
If yes, please describe?
Have you been or will you be in the sun and/or tanning bed within 24 hours of this treatment? *

YesNo
Are you using or have used any of the following in the past 2 weeks:*

Accutane or TetracyclineRetinoids such as Retin-A, Renova or DiferinAHA/Alpha-Hydroxy AcidBHA/Beta-Hydroxy AcidGlycolic AcidNone
Are you taking or have taken Accutane in the past 6 months?*

YesNo
Are you taking any hair growth/health supplements?*

YesNo
Are you taking any other medications?
Are you taking any painkillers or blood thinners?*

YesNo
Are you pregnant or nursing?*

YesNo
Have you had laser hair removal in the past?*

YesNo
If yes, what areas did you treat?
Do you have moles/skin growths, tattoos or scars in the area to be treated?*

YesNo
Do you have any of the following conditions?

EpilepsyEczemaDermatitisPCOSHormone ImbalanceAutoimmune DiseaseHerpes SimplexDiabetesNone
Have you had any injectables or implants in the past two weeks?*

YesNo
If yes, where?
Have you had any other cosmetic procedures?*

YesNo
If yes, please explain?
Have you used any of these hair removal methods in the past six weeks?*

ShavingWaxingTweezingThreadingDepilatoriesNone
Is there anything else you would like me to know?
Laser hair removal is a non-invasive laser treatment designed to remove unwanted hair from all parts of the body. It is important not to wax, tweeze, have electrolysis procedures or pluck hair for 2-4 weeks prior to your appointment. It generally takes 10 to 21 days after the procedure for the treated hair to fall out. Treatment of dark course hair generally achieves the best results while removal of light fine hair generally requires additional treatments which may or may not be successful. Results may also vary depending on individual skin type, hormonal levels and hereditary influences. Therefore, some patients may experience partial results and some may notice no improvement at all. Future hormonal changes may cause additional hair growth.

LHR procedure generally involves a series of treatments. Ideal (light skin/dark hair) candidates can usually achieve 65%-90% reduction with a series of 5 treatments. Thicker skinned areas such as backs, faces or neck usually require more than 6 sessions and usually achieve only partial reduction or hair thinning. Some re-growth of hair may occur after treatment sessions are completed. Long term maintenance is usually needed.Generally you are not a good candidate for LHR procedure if you are pregnant, nursing or plan to become pregnant while undergoing LHR treatments. Individuals who have used Accutane within the past six months or who used any medications requiring limited exposure to sunlight are not good candidates for LHR procedure. Individuals with recently tanned skin are advised to delay undergoing the LHR procedure. The laser is not effective on blond or gray hair. Sun exposure 2-4 weeks prior to treatment may reduce effectiveness of the laser. It is important to shave the area prior to treatment session. All medical and cosmetic procedures are associated with certain risks and may result in complications.4

Possible risks and complications associated with LHR procedure include:

• Temporary reddening, burning, swelling, bruising or discoloration of the skin over the treated area.

• Hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin), which rare may take several months to fully resolve

• Crusting or blistering of the area exposed to laser, which is rare and which may take several days to heal.
I have been advised that the services provided to me by this salon could have unfavorable results including, but not limited to: allergic reaction, irritation, burning, redness, soreness, ect. I am aware that certain medications and over the counter products can significantly increase the risk of injury when combined with skin care services. I understand that Mode Beauty NYC does not recommend skin care services for customers using Retin-A, Accutane and products contacting alpha hydroxyl or any other skin thinning treatments. I hereby confirm that I am not using any medications that may cause or contribute to such injury/reaction, and I will advise my esthetician should I use any such medications in the future. I understand there are often inherent risks associated with skin care services, and I agree that as a condition of providing these services on an on going basis, I will not hold Mode Beauty NYC and Esthetician liable.
Initial Here*
I acknowledge that I must adhere to Mode Beauty NYC’s cancellation and late policies. I understand that appointments should be canceled with at least 24 hours notice to allow availability for other clients.

I also understand that if I arrive more than 10 minutes late, my appointment may need to be adjusted, rescheduled, or canceled based on the remaining time available.
Initial Here*
At Mode Beauty NYC, your satisfaction is my top priority. If, for any reason, you’re not fully satisfied with your service or product, I kindly ask that you adhere to the following guidelines:

If you have any concerns about a service or product, please reach out to me directly within 24 hours of your appointment or purchase.

Before posting a review or sharing your concerns on social media, I kindly request that you allow me the opportunity to address and resolve the issue. My goal is to ensure you leave feeling confident and cared for.

If necessary, I may request that you come in for an in-person assessment. This will allow me to better understand your concerns and determine the best course of action to address them.

Please note that all services and packages are non-refundable. However, I am committed to doing everything possible to make your experience positive and meet your expectations.

Exchanges for products may be available within 24 hours of purchase at my discretion. Please provide details about your concerns to help me better understand how to assist you.

By initialing here, I acknowledge and agree to these terms
Initial Here*
PHOTOGRAPHY CONSENT
I grant my permission to be photographed and/or video recorded by my treatment provider in order to keep a thorough record of my treatment progress and to promote the skincare services of this facility and my treatment provider. I understand that the images and/or recordings may be used in print and/or online publications, presentations, websites, and social media. I
understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. I also understand that the images
may be retouched as seen fit by my treatment provider. I consent to these terms on the condition that I will be made aware at the time of any
and all photography/recordings, and none shall be taken without my knowledge.
I consent to my photos being used for marketing, social media and other sources(only non-sensitive areas such as underarms, legs, face, arms, etc.)I DO NOT consent to my photos being used for marketing, social media or other sources.
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Date *

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Parent or Legal Guardian name if minor
Parent or legal guardian signature:

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