Laser Form

ILLUME Skin Spa

Laser hair removal
Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Phone/Cell Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your Gender?*

MaleFemale
Check the Skin Type that best describes you?*

Always burns, never tansAlways burns, sometimes tansRarely burns, always tansNever burns, always tansBrown, moderately pigmented skinBlack Skin
Have you used any of these products in the past? (I understand I will need to avoid treatments or the use of the products below during the entire laser hair removal treatment to avoid complications. If I'm unable to receive the laser treatment because of the use of the treatments/products below, I will be charged a last minute cancellation fee).*

Retinol (10 days)Chemical Peels (4 weeks)lactic, glycolic acid, vitamin C or salicylic acid products (7 days)?Sun Burn (2 weeks)Waxing, Tweezed or used Bleaching (4 weeks)Microdermabrasion/Dermaplaning (3 weeks)Laser Resurfacing (4 weeks)None
Please Check any of the following that apply to you?*

Accutane in the past 6 monthsPregnantBreast feedingActive cancerHyper/Hypo pigmentation concernsUse self tanners or tanning bedsSun batherActive psoriasis/eczemaRecent facial surgeryCold soresSkin disease/leisionsHIV/Aids, Hepatitis etcActive infectionSeizure DisorderNoneOther
Please check any medications that you are currently taking*

AntibioticsAnticancer drugAntidepressantsAntihistaminesAntihypertensivesAntiparasiticsNoneOther
What areas are you interested in for Laser?*

FaceBackUnderarmsBikiniBrazilianNeckLegsArms/Hands/FeetOther
Shaving Policy*

I understand that I need to shave the area I am treating at least a day before my appointment, if I don't follow this recommendation I will not be able to get the laser treatment and a cancellation fee will be applied.
Consent & Information Regarding Laser Hair Removal
COMPLICATIONS (which can be PERMANENT) - of this procedure include but are not limited to -
• Burns – Laser treatment can result in blistering/crusting/ flaking of the treatment areas, including tattoo.
• Scarring – can occur when the skin surface is disrupted / when a burn heals. Follow post procedure instructions carefully to minimize the risk of scarring
• Discoloration - Skin Color changes, either lighter (hypopigmentation) or darker (hyperpigmentation) may occur. Usually temporary but can become permanent
• Eye Hazard – use the provided protective eyewear at all times during the treatment to protect eyes.
• Bruising
• Blister/Scab and Skin Infection
• Drug reactions or interactions
• Mismatch in color or texture of the skin including treatments and tattoo.

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

I understand the procedure and accept the risks, and request that the provider at Illume Skin Spa perform this procedure.
This consent is valid for all my Laser Hair Removal treatments in the future as well.

I understand that this procedure works on the growing hairs and not on dormant hairs. For this reason, complete destruction of all hair follicles is not possible and I understand that I will require several treatments to obtain a significant, long-term reduction of hair growth.

I also understand that some people may not experience complete hair loss even with multiple laser treatments.

All 8-session laser packages need to be completed within ONE YEAR after the first visit.
Cancellation Policy*

I AGREE THAT A 48 HOUR NOTIFICATION IS REQUIRED TO AVOID A $50 CANCELLATION FEE OR A $50 RESCHEDULING FEE. I UNDERSTAND THAT IF I AM 10 MINUTES LATE FOR MY APPOINTMENT IT WILL BE CONSIDERED A NO-SHOW AND THE CANCELLATION FEE WILL BE APPLIED. I AGREE TO THIS POLICY AND CONSENT THE SPA TO CHARGE MY CARD ON FILE THAT WAS PROVIDED WHEN BOOKING.
Signature*

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ILLUME Skin Spa

Consent & Information Regarding Laser Hair Removal