MEDICAL HISTORY

If you are currently pregnant, or when you do become pregnant, we will need to discontinue any laser related services for the full term of your pregnancy, as mandated by our insurance company.  There has been no evidence that laser is unsafe for the unborn child, but it is best to avoid it just to avoid the possibility of any complications. 

You are scheduled for a series of non-invasive treatments with the Emsculpt Neo®,  the first and only non-invasive body shaping procedure that uses radiofrequency heating for fat reduction and high intensity focused electromagnetic energy (HIFEM®) for muscle strengthening and toning in a 30-minute session. The end result is more fat reduction and muscle growth than any single gold standard product, for less time and less money. Best of all, EMSCULPT NEO has a broad patient appeal as it can treat patients up to BMI 35.

First introduced in 2018, clinical studies show on average a 30% reduction in subcutaneous fat and a 25% increase in muscle volume.

The procedure is simple and easy. There is no preparation required.  Keeping your body well hydrated is strongly recommended. On the day of the treatment, you are advised to wear comfortable clothing that allows flexibility for correct positioning during the treatment. To avoid excessive sweating, the treated area should be
shaved or trimmed. Also, the treated area may be wiped with alcohol wipes before treatment to remove any moisture, perfume, moisturizers, or oils. You will be asked to remove all metallic accessories and electronic devices. 

You will lay down while the applicators are applied over the treatment area for 30 minutes. During the treatment you may feel intense yet tolerable muscle contractions along with a heating sensation which is comparable to hot stone massage.  The treatment does not require anesthesia. It is important to note that the sensation may be intense, but it should never be painful. Please ask your provider to adjust the intensity should you feel any serious pain or discomfort.  Once the procedure is completed, you can immediately get back to your daily routine.

Protocol is usually 4-6 thirty minute treatments, scheduled 5-10 days apart.  There is no downtime.

Results vary but the best time to see the final results is in 3 months after the last treatment.  Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments, depending on your goals and for long term results.

For a full range of contraindications, warnings and cautions, speak to your technician.

Please review these answers with your technician as you may not be medically cleared for this procedure. 

TREATMENT CONSIDERATIONS
You are scheduled for a series of non-invasive treatments with the BTL EMSELLA device.

BTL EMSELLA is intended to provide entirely non-invasive electromagnetic stimulation of pelvic floor musculature for the purpose of rehabilitation of weak pelvic muscles and restoration of neuromuscular control for the treatment
of urinary incontinence.

Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 6. The treatment is typically about 28 minutes per session, with sessions separated by at least 2 days, depending on your needs.

Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on the severity of your condition. The results will typically continue to improve over the next few weeks.

There is typically no pain associated with your treatment and there is no anesthetic required. You will experience a gradually increasing tingling feeling and muscle contractions. These sensations in the pelvic area are normal and expected. You remain fully clothed during the treatment.

Please wear comfortable clothes which allow flexibility for correct positioning and increased comfort during the treatment.

For a full range of contraindications, warnings and cautions, speak to your technician.

I have requested that Luminesse Laser perform the TED procedure.

CONSIDERATIONS:
While undergoing this procedure, it is important to be aware of various aspects that
may be associated with it.

1. Discomfort and Sensations: Although very unlikely, I acknowledge that I may experience some discomfort during and after the Procedure.
2. Potential Effects: While uncommon, there may be some effects associated with the procedure, such as changes in the treated area's appearance or sensations during the healing process.

CONTRAINDICATIONS:
I understand that certain conditions must be met for the procedure to be performed.

1. I confirm that I am not pregnant.
2. I am over the age of 18.
3. I agree to comply with any relevant instructions.

OUTCOME VIABILITY:
I am aware that this procedure may yield varied outcomes, and it may require
additional sessions for optimal results.

PHOTOGRAPHY CONSENT:
For accurate record-keeping related to my care and treatment, I hereby
consent to close-up photographs of the involved area(s) before, during, and after
treatment. These photographs will be used exclusively for medical records and will be treated with the same confidentiality as the remainder of my clinic records.

If you answered yes to either of the questions above, you are not a good candidate for cavitation at this time.  

CAVILIPO ACKNOWLEDGEMENT:

My questions regarding the CaviLipo procedure have been answered satisfactorily. I understand the procedure and accept the risks. I understand that my Cavi-Lipo body slimming contour session is provided to assist with the reduction of adipose tissue (fat) within my body. I understand that this service is most effective and likely to last if I maintain a healthy lifestyle of proper eating and exercise. I understand that my results may vary from other users and are not guaranteed. I have stated all known medical conditions and I will keep the technician updated on any changes regarding my health. I claim full responsibility for services rendered and receive them at my own risk. I certify that I am a competent adult of at least 18 years of age.

I hereby release Luminesse Laser, LLC (facility and technician) from all liabilities associated with the above indicated procedure.

To the Client: You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment.

1. I voluntarily request that the aesthetician at Luminesse Laser perform the peel procedure. I acknowledge having been informed that this cosmetic procedure is intended to remove surface layers of the skin to improve the vitality of the skin.
   
   
2. Peels, despite their high levels of efficacy and safety, are not free of side effects. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to seven days or longer. Irritation, itching, and/or mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.
   
   
3. It is important to use sun screen of SPF 25 or greater when exposed to the sun.
   
   
4. I understand complications can include white heads, cold sores, infection, scarring, numbness and permanent discoloration, particularly in people with dark skin.
   
   
5. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results. Most patients require a number of treatments over several months with gradual results occurring over this time. Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received.
   
   
6. I have read and understand the Pre and Post-Treatment Instructions. I agree to follow these instructions carefully.

CHEMICAL PEEL ACKNOWLEDGEMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I have read and understand this agreement and I understand that I have the right to refuse treatment.

HydraFacial is the only hydradermabrasion procedure that combines cleansing, exfoliation, extraction, hydration and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little-to-no downtime. The treatment is soothing, moisturizing, non-invasive and generally non-irritating. As with most procedures, visible results from HydraFacial will vary from person to person.

What to expect:

• Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.
• You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.
• Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
• You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
• The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.

HYDRAFACIAL ACKNOWLEDGEMENT:

I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.
Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.

The information provided has been explained to me and all my questions have been answered to mysatisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment performed by the staff at Luminesse Laser, LLC.
By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

The purpose of this procedure is to diminish or remove unwanted hair. The procedure requires more than one treatment and may produce permanent hair removal. The total number of treatments will vary between individuals. On occasion there are patients that do not respond to treatments. The treated hair should exfoliate or push out in approximately 2-3 weeks. Alternative methods are waxing, shaving, electrolysis and chemical epilation.

The following problems may occur with hair removal:

1. There is a risk of scarring.
2. Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation (browning) and hypo-pigmentation (lightening) have also been noted after treatment. These conditions usually resolve within 3-6 months, but permanent color change is a rare risk.
   Avoiding sun exposure before and after the treatment reduces the risk of color change.
3. Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
4. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.
5. Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. Systemic reactions (which are more serious) may result from prescription medicines.
6. I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.
7. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring and hyper-pigmentation.

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

HAIR REMOVAL ACKNOWLEDGEMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks.

I hereby release Luminesse Laser, LLC (facility and technician) from all liabilities associated with the above indicated procedure.

DISCLOSURE ABOUT MAINTENANCE: There is NO laser on the market that can guarantee 100% complete hair removal, many variables affect your long term results and there is typically some maintenance required.  After you complete your series of sessions, if you find that you are still struggling with excessive or rapid regrowth please be aware that hair growth can be exacerbated by: Medical issues Hormonal Imbalances PCOS High Testosterone Thyroid Disease Pregnancy Adrenal Disorders Medications/supplements Biotin Collagen Steroids Genetics Hirsutism runs in families

Laser tattoo removal isn’t recommended on fresh tattoos (under 3 months old) because the skin is still healing, increasing the risk of scarring, infection, and poor results. The ink needs time to settle for effective removal, and early treatment can cause excessive irritation and complications. Waiting at least 3 months ensures safer, more effective results.  We can consult with you today but you will need to wait to start the removal process.  

Please read thoroughly and make sure you understand the risks. 

While extremely rare, we must be transparent and inform you of all the possibilities.  Once you agree to cosmetic tattoo removal, we cannot be held liable for any of the following:

1. Pigment (Paradoxical) Darkening or Color Changes
Some cosmetic tattoo inks contain iron oxide or titanium dioxide, which can turn darker.  Also, some inks may turn red, yellow or neon green - making removal harder. X X X

2. Skin Damage or Discoloration
The delicate facial skin is more prone to scarring, blistering, and texture or color changes (hypo or hyperpigmentation).

3. Hair Loss in Treated Areas
Laser treatment on eyebrow tattoos may damage hair follicles, leading to temporary or permanent hair loss or lightening.

4. Ineffective Removal
Some inks, especially flesh-toned or white pigments, do not respond well to lasers.

I consent to and authorize Luminesse Laser and members of their staff to perform multiple treatments, laser procedures and related services on me. The procedure planned uses laser technology for the removal of tattoos. 

As a patient you have the right to be informed about your treatment so that you may make the decision whether to proceed for laser tattoo removal or decline after knowing the risks involved. This disclosure is to help to inform you prior to your consent for treatment about the risks, side effects and possible complications related to laser tattoo removal. 

The following problems may occur with the tattoo removal system: 

1. The possible risks of the procedure include but are not limited to pain, purpura, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, infection, and unforeseen complications which can last up to many months, years or permanently. 
2. There is a risk of scarring. 
3. Short term effects may include reddening, mild burning, temporary bruising or blistering. A brownish/red darkening of the skin (hyperpigmention) or lightening of the skin (hypopigmentation) may occur. This usually resolves in weeks, but it can take up to 3-6 months to heal. Permanent color change is a rare risk. Loss of freckles or pigmented lesions can occur. 
4. Textual and/or color changes in the skin can occur and can be permanent. Many of the cosmetic tattoos and body tattoos are made with iron oxide pigments. Iron oxide can turn red-brown or black. Titanium oxide and other pigments may also turn black. This black or dark color may be un-removable. Because of the immediate whitening of the exposed treated area by the laser, there can be a temporary obscuring of ink, which can make it difficult or impossible to notice a specific color change from the tattoo removal process. 
5. Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
6. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary. 
7. Allergic Reactions: There have been reports of hypersensitivity to the various tattoo pigments during the tattoo removal process especially if the tattoo pigment contained mercury, cobalt or chromium. Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive treatment. Noted in some patients are superficial erosions, bruising, blistering, milia, redness and swelling which can last up to many months, years or permanently. 
8. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation. Aftercare guidelines include avoiding the sun for 2 months after the procedure. If it is necessary to be in the sun, a sunscreen with SPF 25 or greater must be used. 
9. I understand that multiple treatments will be necessary to achieve desired results. No guarantee, warranty or assurance has been made to me as to the results that may be obtained. Complete tattoo removal is not always possible as tattoos were meant to be permanent. 

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

TATTOO REMOVAL ACKNOWLEDGEMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks.

I hereby release Luminesse Laser, LLC (facility and technician) from all liabilities associated with the above indicated procedure.

LED Light Therapy

LED light therapy is the process in which certain colors of light are used to trigger naturally occurring physiological processes in the body, including cellular healing and nitric oxide release. Clinical studies show nitric oxide can help increase and support basic functions in nearly every part of the body including, but not limited to, increased circulation, stimulated collagen production, increased lymphatic system activity, and decreased nervous excitability.

Possible Benefits of LED Light Therapy

Reduce the appearance of fine lines and wrinkles by stimulating collagen and elastin production

Reduce the appearance of scars and other skin ailments, such as rosacea by deeply penetrating the skin and promoting growth of skin cells

Treat acne by fighting off and killing the bacteria under your skin

Possible Risks of LED Light Therapy

Overall, the American Academy of Dermatology deems this procedure safe.

Side effects from LED light therapy are rare and were not noted during clinical trials, may include:

• redness
• rash
• pain
• tenderness
• hives
• increased inflammation

* If you checked off any of the contraindications listed above, you must get approval from a licensed physician prior to your service.

LED LIGHT THERAPY ACKNOWLEDGEMENT:

By signing this document, I understand, have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/ or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Luminesse Laser, LLC from liability and assume full responsibility thereof. I am aware that individual results for any treatment offered may vary. Results are not guaranteed.

You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment.

1. I understand that I will undergo Teeth Whitening treatment(s) using gel solution and a LED (Light Emitting Diode) device.
2. I understand that multiple treatments may be necessary to achieve desired results. Treatments are 15 to 20 minutes per session. Additional treatments may be necessary to maintain desired results. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment.
3. Possible side effects can include but are not limited to: Allergic reaction to the gel solution, tooth sensitivity and irritation of the soft tissues (particularly the gums). In rare cases the use of LED’s can damage the pulp (soft tissue in the center of teeth) of teeth. Repeated teeth whitening may damage teeth.
4. I understand that if I am not being treated by a dentist, my technician has no dental qualifications and that my teeth are not being examined for health, cavities, etc.
5. I am aware that I should be examined by a dentist prior to treatment. I will advise my technician if I had/have any cavities or other dental work in my mouth.
6. I understand that if I have veneers, porcelain, or other dental materials in my mouth, that these materials can not get any whiter than their original color.
7. I understand I am not a good candidate for this procedure if I have significant periodontal disease, fillings that may be breaking down, unfilled cavities, or chipped or warn teeth. I understand if I have any of these conditions I will advise my technician.
8. If I am pregnant I understand that I may receive the LED Teeth Whitening service, however; I must first consult with my doctor.
9. If I am provided with a home whitening treatment kit, I will follow the instructions provided by my technician. I will not use the product more than instructed.
10. I have read and understand the Pre and Post-Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of side effects and complications as listed above.

The nature and purpose of the treatment have been explained to me. I have read and understand this agreement.  All of my questions have been answered to my satisfaction and I consent to the terms of this agreement.

LED TEETH WHITENING ACKNOWLEDGEMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I certify that the preceding dental history statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical or health conditions and to update this history. I certify that I am a competent adult of at least 18 years of age.

I hereby release Luminesse Laser, LLC (facility and technician) from all liabilities associated with the above indicated procedure.

MEDICAL HISTORY

Please indicate the body part:

MASSAGE ACKNOWLEDGEMENT:

My questions regarding the procedure have been answered satisfactorily. It is my choice to receive massage and I give consent to receive treatment.

The light pulsed system may dramatically reduce darkly pigmented sunspots and spider veins. More than one laser session may be necessary to achieve desired results. However, other treatments, including skin care products, are often needed to blend color, reduce sun damage, and give the best results. The FDA has given the clearance for removal of brown spots, spider veins, and rosacea.

The skin treated will be red and swollen with fine, thin scabs forming. Keep the treated areas covered with coconut oil or Aquaphor until the thin scabs fall off. This process will take anywhere from 1-3 weeks. It could take as long as 3-6 months in some rarer cases. Do not scratch the scabs, as that can cause scarring.

The following problems may occur with treatment:

1. Scarring: The light pulsed system can create a bruising and a moderate burn or blister to the skin. For an effective treatment, the power
   (joules) needs to be just below the blistering point which means skin will be red. There is a risk of scarring.
   Hyper-pigmentation (browning) and hypo-pigmentation (whitening) have been noted after treatment, especially with a darker complexion. This usually resolves within weeks, but it can take as long as 3-6 months in some cases. Permanent color change is a rare risk. If you have a lot of color in your skin, a skin lightening cream will be advised to reduce the melanin in your skin before the treatment. Avoiding sun exposure after the treatment is crucial to reduce the risk of color change.
2. Infection: Although infection following pulsed light treatment is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a laser treatment. This applies to both individuals with a past history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatment including antibiotics may be necessary. If you have a history of herpes simplex virus in the treated area we recommend preventative therapy.
3. Bleeding: Pinpoint bleeding is rare but can occur following brown spot and spider vein treatment procedures. Should bleeding occur, additional treatment might be necessary.
4. Skin tissue pathology: Energy directed at skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible. Only clearly benign pigmented lesions can be treated. Check with your doctor for a clearance for the
   treatment.
5. Allergic reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations, have been reported. Systemic reactions (which are more serious) may result from prescription medicines. Allergic reactions may require additional treatment.
6. Wear sunscreen of SPF 25 or higher before and after treatment to protect your skin.
7. I understand I may need multiple treatments for the desired outcome.
8. I understand that exposure of my eyes to light could harm my vision. I will keep the eye protection on at all times.
9. Compliance with the aftercare guidelines is crucial for healing, prevention of scaring, hyper-pigmentation and hypo-pigmentation.

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

SKIN REJUVENATION ACKNOWLEDGEMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks.

I hereby release Luminesse Laser, LLC (facility and technician) from all liabilities associated with the above indicated procedure.

Laser Smoking Cessation Therapy is a scientific approach to help people quit smoking, which combines the latest technology in cosmetic lasers and an appropriate appointment plan to reduce the cravings to smoke. There is a great deal of variation in the types of lasers that are used and how they are used. Each type of laser has its own emitted wavelengths at specific tuned in frequencies which all utilize Low Level Laser Therapy (LLLT) treatments. The laser is then applied to specific body points to induce the release of endorphins mimicking the effect that smoking would have on the receptors in your brain. As a result your brain gets the same endorphin-like calming effects without the actual act of smoking. Laser Therapy causes these endorphins to be continuously released for an extended period of time, diminishing the physical craving to smoke.

The Low Level Laser Therapy used will be able to penetrate the skin without any heating effects or invasive procedures. This process will not damage the skin and has very few side effects, with very little, but mostly zero pain or discomfort. Some of the side effects include, but are not limited to: increased circulation, promoting cell growth, and loss in blood pressure.

Smoking cessation laser therapy should not be used for patients whose health conditions are susceptible to excess growth of cells. For example patients suffering from blockages, tumors, cancer, those undergoing radiation or epilepsy cannot be allowed to undergo laser treatment. Also pregnant women should not undergo laser therapy. Any person belonging in the categories stated above are advised to make use of alternative methods to cease smoking.

Scientific research failed to disclose any significant and measurable results associated with laser cessation therapy and so there are no guarantees with its success. Also it has been concluded that laser treatment therapy is no better nor worse than any other forms of alternative smoking suppressants. Some alternatives to Smoking Cessation Therapies are:

• Patches
• Gums
• Prescription Pills
• Hypnosis
• Acupuncture
• Counseling

SMOKING CESSATION ACKNOWLEDGEMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks.

I hereby release Luminesse Laser, LLC (facility and technician) from all liabilities associated with the above indicated procedure.

You have purchased one or more spray tans to develop a tan on your skin. To help achieve your desired results, please read and sign the following material carefully.

1. A spray tan will not prevent your skin from burning in the natural sun or in a tanning bed. A spray tan does not contain sunscreen and does not protect against sunburn. Repeated exposure of unprotected skin while UV tanning may increase the risk of skin aging, skin cancer and other harmful effects to the skin. Please take the proper precautions when tanning with UV light exposure.
   
   
2. For best results, wait 8 hours after spray tanning before showering or engaging in any activity that will cause you to perspire, unless otherwise advised by our staff. This will allow your tan to fully develop and will ensure the longest results.  No workouts until after your first rinse.  Your tan will take 24-48 hours to fully develop, so for special occasions, coming 2 days in advance is suggested.  
   
   
3. You will be manually sprayed by a spray tan artist with our HVLP spray tan machine. However, as clients are different heights and shapes, and may stand in different positions, there is always the possibility that you may notice some areas of your tan lighter than others. In most cases, these differences are minor and disappear as your tan fades naturally. 
   
   
4. Our spray tan room is fully ventilated and we provide footies to keep the soles of your feet clean.
   
   
5. More than one tan session per week is not recommended.
   
   
6. All of the components of our tanning solutions have been used in cosmetics for decades and have proven to be safe for the skin. However, that does not mean you cannot have an allergic reaction.  Although this would be extremely rare, if you have ever had any adverse effects from our tans, consult a healthcare professional and please let us know about the incident.  
   
   
7. The FDA has approved DHA (the active ingredient in sunless spray tanning) for external application to the skin. For misting applications, the FDA recommends protective measures to prevent eye contact, inhalation or ingestion. To ensure complete protection, the FDA suggests wearing protective eyewear, nose filters, ear plugs, lip balm and undergarments.
   
   
8. Our spray tanning solutions include a cosmetic bronzer which is water soluble and will be removed after your next wash. However, in some instances, the DHA in the tanning solution may permanently stain undergarments worn during the spray session.  This solution will give you an immediate bronzing effect. The bronzing effect is the result of a coloring additive in the solution that will remain on the skin until you are actually tan. It will progressively get darker and may be alarming, but rest assured that when you shower, the heavy coloring will come off to reveal your actual tan beneath. 
9. Please protect car seats, fabrics and leather, or porous surfaces you may sit on with a towel to prevent staining. Clean toilet seats post use. Use dark sheets on bedding to prevent color guide bronzer transfer stains.
   
   
10. Tanning solution cannot penetrate hair follicles but many customers wear disposable hair nets (provided by the salon) to keep the solution from getting in their hair. There is no evidence that the tanning solution can change hair color.
    
    
11. If you have any history of asthma or a respiratory condition, or you are pregnant, consult your physician before spray tanning, and do not use if you have had any past allergic reactions to DHA products.
    
    
12. For best results, shave and exfoliate at least 12 hours in advance, shower off any products, deodorants and oils on your body, and only use gentle skincare products until the tan is fully worn off.  
    
    
13. You may also want to apply a water base moisturizer onto areas that are dry or have natural creases to avoid the solution settling into those areas.  Just a thin layer will help. 
    
    
14. Keep in mind that your tan will last longer if you treat it gently, no heavy soaps or exfoliants - clear soap vs milky soap.  Submersing in pool or ocean water for long periods of time, intense workouts and saunas will obviously accelerate the wear-off of your tan.   
    
    
15. To help remove the tan once it starts to wear off, you can exfoliate, scrub, soak, and use oil based products.
    
    
16. Be advised there is a small percentage of people whose skin may not react favorably to a particular spray tan solution. For this reason, we do NOT advise being sprayed for the first time when your appearance is critical; (wedding/special occasion) and we strongly advise doing a trial. 
    
    
17. Wear loose clothing and if you can avoid fitted bras or underwear immediately after your tan.
    
    
18. During developing time, clean palms with wet wipes only - but if product transfers onto them, you can use alcohol based facial toner or nail polish remover.
    
    
19. Keep in mind, every person has a unique skin chemistry and amino acid makeup, which will make every tan unique, and specific to you. The color, shade, and appearance will be unique to you, and no two tans, will look identical, even when using the exact same product. Many things may affect the final color and how a tan works on you, with your individual skin chemistry. Skins pigment level, health, normal color tone, porosity, oiliness, your age and life style habits, diet, medications used, hormonal fluctuations, hormonal based medications and supplements, menstruation, pregnancy, and breast feeding, menopause as well as other factors can all change the outcome of your tan color, and how well it develops and wears.

If you ever have any concerns about the way a particular tan comes out vs your expectations, adjustments can be made or we would be happy to use a different solution on you in the future as we work with different product lines and your chemistry may respond better to a different solution.

SPRAY TAN ACKNOWLEDGEMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks.

I hereby release Luminesse Laser, LLC (facility and technician) from all liabilities associated with the above indicated procedure.

This treatment will cause a lot of sweat and you can burn upward of 900 calories with each session.  You may wish to not wear any undergarments because they will get wet during the session.  We will keep you covered and you will never be fully exposed.  Please use the bathroom prior to starting your treatment.  And do not tan the same day as your skin will be more sensitive. 

If you are taking prescription drugs, you should consult your physician
before receiving the Infrared Body Wrap.

Consult with your doctor before receiving an Infrared BodyWrap treatment. We will need written clearance for treatment if you suffer from any of the conditions listed above.

BODY WRAP ACKNOWLEDGEMENT:

I have been fully informed and understand the use of Infrared Body Wrap System and accept personal responsibility for my treatments. I understand that Luminesse Laser and it's staff are not liable for any injury to person caused in any way by the use of its services or premises. I am aware that the results achieved by this treatment may vary from person to person, and I acknowledge that no promises or guarantees have been made to me as to the results of this treatment.

This in-house treatment will help jump start the brightening process by suppressing the melanin in the skin by 1-4 shades.  Areas may brighten differently from one area to another, results vary.  We highly recommend using the take home kit to further your progress and extend the results.

INTIMATE BLEACHING ACKNOWLEDGEMENT:

Clients receiving our skin brightening treatments on any areas that may be exposed to sun must use an SPF of 50 or higher in order to see and maintain results.  

I agree to have an eyelash lift (perm) and/or eyelash tint applied to my natural eyelashes and/or retouched. By signing this agreement, I consent to the procedure of an eyelash perm or eyelash tint by my technician.

I agree to the following eyelash perm post-op and maintenance instructions:

No water can come in contact with the eye area for 24 hours after the application.

This agreement will remain in effect for this procedure and all future procedures conducted by my technician.

I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement.

I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use.

There are no guarantees for length of time the lashes will stay permed. I understand the aftercare instructions and will do my part to maintain my eyelashes.

I understand that there are many factors that may affect the life of the
eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.

I give my consent for Dermaplaning to be performed by the trained and licensed staff of Luminesse Laser.

Dermaplaning is a physical/mechanical form of exfoliation using a specialized dermaplaning blade for the removal of built up dead skin cells and vellous hair.

Following treatment skin will be smoother, softer and better able to absorb the active ingredients in treatment and home care products.

I understand this treatment involves the use of a sterile, surgical blade to remove dead skin cells and vellous hair. As with the use of any sharp instrument, there is the possibility of nicks or cuts.

I understand there are contraindications to this treatment, including but not limited to, diabetes (not controlled by diet or medication), cancer, active acne, bleeding disorders, the inability for blood to coagulate or the development of keloids following injury.

Certain medications including blood thinners, higher dosages of Aspirin, and Accutane are contraindicated for this treatment due to the possibility of delayed clotting from a nick or cut.

While every precaution will be taken to avoid nicks, cuts and scratches, I understand the risks and consent to treatment today.  By signing this waiver, I certify that I am not taking any of the above medications or experiencing any of the above conditions.

CLIENT CONSENT:

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, 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.