Laser Hair Removal Consent Form

Name*

First NameLast Name

Gender*

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth*

Date

Referred by:

First NameLast Name

Date*

Date

Brief Information

Laser hair removal involves the use of a non-invasive laser device for the reduction of facial or body hair. This works on the hairs that are in the active stage of growth and thus, it does not work on dormant hairs.

The procedure for this requires more than one session. Please take note as well that the hair removal session may vary per individual depending on the amount of hair, density, or color. However, on average, we recommend around 8-12 sessions. Laser hair removal is not completely permanent and revisits may be needed for maintenance. Epilation with the Soprano system is a safe alternative to methods used for removing unwanted hair, such as shaving, waxing, chemical epilation, and electrolysis.

Preparatory Care Procedures

Prior to undergoing treatment, one must avoid over-exposure to sunlight or using tanning treatments. Prepare this at least a month prior to the treatment date.

It is likewise necessary to have the area to be treated shaved a day or two prior the appointment date. If the area is not shaved we cannot do laser over that area.

Please do not wax, tweeze, or use hair-removing creams that can affect in greatly decreasing the efficacy of laser hair removal treatments.

It is recommended to check with us if the patient is taking any medications. There are those that can affect the skin's photosensitivity and therefore can be dangerous when undergoing any laser treatment.

Potential Risks and Expectations

The following are possible risks that patients may experience with the hair removal treatment:

Minor wounds. Laser hair removal treatment can result in blistering, flaking of the skin, or sometimes swelling on the surface of the treated skin areas. In such cases, it is recommended that the area should heal first prior to undergoing another treatment.

Discomfort. Patients may experience discomfort during the treatment. Please take note that this is a normal occurrence.

Pigment changes. There is the possibility that there might be a darkening or lightening of the color of the skin during the healing process. This is usually temporary but on rare occasions, it can be permanent.

Eye exposure. Exposure to the eye with lasers can lead to temporary or permanent eye damage. However, please take note that we will provide eye protection during the treatment period. Please keep the protection on during the treatment and do not remove it unless allowed by us.

Scar. Scarring might occur in rare instances, especially if the prior or post procedures are not complied with. Thus, it is important that the pre and post-procedural treatment guidelines are carefully followed.

Post Care Instructions

Avoid scratching, touching, or picking on your skin's treated area as this may get irritated or infected. Avoid any tanning lotion or being exposed under the sun for long periods within the first 3 days after treatment. This may cause hyper pigmentation on the treated area.

Answer the following:

Do you currently or have had cancer, especially malignant melanoma or recurrent non-melanoma skin cancer, or precancerous lesions such as multiple dysplastic nevi?*

Do you have any active infections?*

Do you have any diseases which may be stimulated by light at 515 nm to l200 nm, such as history of recurrent Herpes, Sim- plex, Systemic Lupus Erythematosus, or Porphyria?*

Do you have any Immunosuppressive diseases, including AIDS and HIV infection, or use of immunosuppressive medications?*

Do you have any history of Hormonal or endocrine disorders, such as polycystic ovary syndrome or diabetes, unless under control?*

Do you have any history of bleeding coagulopathies, or use of anticoagulants?*

Do you use of photosensitive medication and/or herbs that may cause sensitivity to 515 - 1200 nm light exposure, such as Isotretinoin, tetracycline, or St. John's Wort?*

Do you have any history keloid scarring?*

Do you have any skin conditions that cause dryness of the skin?*

Have you been exposed to the sun or artificial tanning during the 2 weeks prior to the treatment?*

Are you pregnant?*

Are you currently taking any medications (including aspirin)?*

What is your daily consumption of alcohol?*

Do you have any allergies? If so, which ones?*

Which alergies?

Are you taking any herbal supplements (St. John’s Wort, etc.)? If so, which ones?*

Which herbal supplement?

Do you wear contact lenses?*

What’s your skin type?*

How easily do you tan?*

When were you last exposed to the sun(including tanning booth)?*

Do you use any chemical sun tanning lotions?*

Are you planning a holiday in the sun?*

Which body part is being treated?*

Do you have prior laser treatment?*

I understand that treatment by the Soprano laser hair removal system involves a series of treatments, and the fee structure has been fully explained to me Client Initials* .

I duly authorize the following technician to perform the Soprano ICE Laser Hair Removal procedure and any other measures which in their opinion may be necessary.

I understand the risks involved in the procedure and I understand that I may need to undergo several treatments in order to obtain my desired results.
I understand the pre and post-treatment procedures needed for me to comply with upon undergoing the laser hair removal treatment.
I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and complications, and I understand that no guarantee can be given as to the final result obtained.
I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
I confirm that I am not pregnant at this time, and that I have not taken Accutane within the last 6 months. I do not have a pacemaker or internal defibrillator.
I have asked questions which are unclear to me and I have received explanation about them to my satisfaction.
I declare that I am of legal age and can exercise this consent with full discretion and responsibility to being legally bound under the terms and conditions of the treatment.

Date Signed*

Date

Signature*

Client Settings

Rows	Fluence	Energy	Notes
Face
Neck
Chest (Areola)
Stomach
Legs
Arms
Underarms
Brazilian/Labia
Buttocks
Other

Client Session Logs

Rows	Any changes? If no, sign. If yes, describe below.	Details (Describe where settings were changed)	Date	Initials
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Session 7
Session 8
Session 9
Session 10
Session 11
Session 12

Sections below to be completed after all laser sessions