LASER HAIR REMOVAL INTAKE & CONSENT FORM

Full Name

Email

example@example.com

Address

Street Address Line 2

CityState

Zip

Phone number

Occupation

How did you hear about us?

What are your primary concerns? (Check all that apply)

Medical Conditions: (Check all that apply)

Have you ever experienced any adverse reaction to any treatment?

List any allergies

Are you taking any Medications/Supplements?

Haven you taken any of the following medications in the last 3 months?

Have you had/used any of the following in the last 2 weeks on the area to be treated? (Check all that apply)

(FEMALE CLIENTS ONLY) Any chance of pregnancy?

(FEMALE CLIENTS ONLY) Breast feeding?

(FEMALE CLIENTS ONLY) BIRTH CONTROL?

(FEMALE CLIENTS ONLY) REGULAR PERIODS?

(FEMALE CLIENTS ONLY) PCOS?

Have you had dermal fillers in the last 6 weeks?

Have you used Isotretinoin within the last 6 months?

Have you used products containing any of the following ingredients in the last 2 weeks on the area to be treated? (Check all that apply)

Have you had any previous laser/ IPL treatments?

Do you currently have a spray/sun tan?

Please indicate how your skin responds to midday summer exposure with no sunscreen

Antibiotics and any other photosensitizing medications
Waxing, tweezing, bleaching, and hair removal creams (shaving is acceptable)
Prolonged sun exposure, tanning beds & self tanners
Chemical peels, microdermabrasion, botox/fillers and other laser procedures
Prescribed topical medications, including Retin A, Tazorac, Differin, etc.

Abrasive products containing retinol, alpha and beta hydroxy acids (AHA/BHA), hydroquinone/bleaching creams, benzoyl peroxide

Arrive fully shaved and make sure all creams, lotions, makeup and deodorants are removed. It is recommended to wait at least 12 hours before reapplying makeup and at least 3 hours before reapplying deodorant after each session.
If applicable, apply numbing cream 30 mins before.
PLEASE NOTE: If you are pregnant, all laser treatments must be stopped immediately.

SPF 30+ Sunscreen is required on all treated and exposed areas between sessions.

AVOID:

Products with alcohols, bleaching creams, perfumed products (i.e. aromatherapy oils) for 24 hours.
Gym activity for 24 hours.
Hot showers, saunas, hot tubs, swimming and extreme sports for 48 hours.
Abrasive skin care products and exfoliation for 1 week.
Waxing, tweezing, bleaching, and hair removal creams (shaving is acceptable) between sessions.
Prolonged sun exposure and tanning beds/self tanners for 2 weeks.
Chemical peels, botox/fillers and other laser procedures in the area for 2 weeks.

LASER/LIGHT ENERGY WAIVER

I consent to and authorize MUSE SKIN LAB NYC to perform laser treatments on me and will hold them and their staff harmless from any liability that may result. Laser, despite its high levels of efficacy and safety, is not free of side effects. I understand my first treatment session will be at a more conservative treatment level for the safety of my skin. For subsequent treatments the technician may increase the treatment energy for increased efficacy, but can also increase the potential of unwanted side effects. The technician will obtain a treatment level which is ideal for my skin, but will error on the side of safety first: Erythema (redness), edema (swelling) and a mild burning sensation much like a sunburn can occur but usually subsides within a few hours. Pigmentary changes such as hyper pigmentation and hypo pigmentation of the skin in the treatment areas can occasionally occur. Most are transient, lasting up to six months, but in rare cases can be permanent. Other known but rare complications of this procedure include scaring, keloids, blisters, reddening, bruising, superficial crusting, burns, pain, and infections. understand that the treatment may involve risks of complications or injuries from both known and unknown causes, and I freely assume these risks. There may be other treatment options, such as other types of lasers and light sources. With this in mind, I am choosing this noninvasive treatment for hair removal. Eye damage can occur from the light and therefore protective eyewear must be worn during all laser sessions.

I received, read and understand the Pre and Post-Treatment Instructions. I was informed to avoid sun exposure for two weeks before and after the treatment. I agree to follow these instructions carefully. Additionally, I was informed of the treatment contraindications. I hereby declare that I do not suffer from any skin ailment, skin problems or any other sickness or medication usage that prevents me from undergoing the laser treatments. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that maintenance treatments for removing new or undamaged hair might be needed from time to time. Achieving the expected results requires repeated treatment within a period which varies in accordance to the selected treatment. The expected results in hair removal may require a time period of 1.5 years or more, in cases of hormonal disorder. Clinical results will vary. I give permission for my photographs to be used. Such uses include but are not limited to the display of videos and digital images on Muse Skin Lab's website and social media pages. 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. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment. Additionally, I certify that the preceding medical, personal and skin history statements are true and correct. This consent applies to current and future treatments; if there is any change in my medical history, I will notify the treatment staff as a current medical history is essential to execute appropriate treatment procedures.

Cancellation Policy: Your appointment time is reserved just for you and leaves a gap if you miss it. In the case you are unable to keep your appointment, you must notify Muse Skin Lab at least 48 hours prior to your scheduled appointment time to avoid the cancellation fee of $25 for single areas, $50 for multi-areas, $75 for Full Body appointments. Please note that all guests are considered late 15 minutes after the appointment time. It may be necessary to reschedule your appointment and may be subject to the cancellation fee. Please note if there is no card on file and the no-show fee isn’t paid, the session is redeemed.I am aware of the Cancellation Policy.

Financial Responsibility: Packages must be paid in full to receive discount. Promotions: One promo per service per client. Not combinable. All promotions including packages expire 12 months after purchase.

Refund Policy: All sales are final, however, any amount paid may be used toward another service or a gift card at full discretion of the spa. In case of a refund, the full cost of each service used (before discount) will be deducted from the amount paid. Any fees including processing and banking fees will be deducted from the amount paid.

Technician Assignment: At Muse Skin Lab, all of our laser technicians are licensed, extensively trained, and certified to perform laser services with the highest standard of care and professionalism. While we understand that you may have a preferred technician, we cannot guarantee technician availability for every appointment. • Technician requests are not guaranteed.• All technicians follow the same treatment protocols and have received in-house training to ensure consistent results and safety. • If you arrive to your appointment and your preferred technician is unavailable, you will still be expected to proceed with the service.• If you choose not to proceed with the service at the time of your appointment due to technician preference, this will be considered a no-show and the standard no-show fee will apply. By signing below, you acknowledge and agree to this policy.

Results disclaimer: Laser hair removal results may vary depending on individual factors such as skin type, hair color, hormonal influences, and adherence to the recommended treatment schedule.Inconsistent treatments or failure to follow the advised intervals may reduce the overall effectiveness of the results.Maintenance sessions may be required. No guarantees are made regarding the number of sessions needed or the permanence of results.

Contraindications: Please make sure to review the Pre/Post instructions as any contraindications not followed will avoid you from receiving services and result in a cancellation fee. For Laser Hair Removal appointments, make sure to fully shave the areas you plan to laser the night before and note there is an additional $10.00 charge for shaving in office and appointment may need to be rescheduled.

Are you comfortable being photographed or recorded during your treatment?

Signature

Print Name

Date

LASER HAIR REMOVAL CONSULTATION FORM

PRE-TREATMENT INSTRUCTIONS

2 WEEKS BEFORE DISCONTINUE:

1 WEEK BEFORE DISCONTINUE:

ON THE DAY OF YOUR APPT:

POST TREATMENT INSTRUCTIONS