Laser Hair Removal Consent Form

Laser Hair Removal Consent Form
, , hereby authorize and direct Lauren Holmes or another Certified Laser Technician to perform laser hair removal treatments on me.
The Cynosure Apogee Elite targets pigment in the hair follicle to treat unwanted pigmented hair for long-term hair reduction. Hair grows in 3 cycles (Anagen Catagen & Telogen). The laser works during the Anagen or “growing phase” of hair growth. Therefore, multiple treatments are needed at regular spaced intervals
(4-8 weeks) to treat all of the hair in a treatment area for significant reduction of hair growth. For maximum results, it is necessary to follow the recommended treatment schedule.
Laser therapy is not recommended if any of the following conditions exist:
(Please check any current medical conditions!)
(Please check any current medical conditions!)

Lupus / Auto-Immune DeficiencyAccutane Treatment(6 Months)On AntibioticsDiabetesPregnant or NursingKeloid or Thick ScarringEpilepsyBleeding AbnormalitiesActive Herpes Simplex / Fever BlistersScars that turn white or brownDark Spots after PregnancyPsoriasis or VitiligoLeg Ulcer or PhlebitisBlood ThinningRheumatoid ArthritisCystic AcneHIVHepatitisWaxing/Plucking in last 4 weeksHirsutismTransplant Anti-rejection DrugsSkin CancerSurgical ImplantsMetal ImplantsChemical Peels (2 weeks)Microdermabrasion (2 weeks)Laser Resurfacing or Facelift (8 weeks)Pregnant or NursingPhotosensitivity DisorderSeizure Disorder(triggered by light)Active InfectionSun TanBotox or Filler (2 weeks)None
I have notified my treating clinician if I have one or more of the conditions above.
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I understand that treatment is not recommended for tanned patients until the tan has faded and that sun exposure must be avoided between treatments. I have not tanned, and will not tan, in the areas to be treated during the entire treatment course and for six weeks before and after treatment. This includes sun exposure and tanning booths. Artificial tanning products must be discontinued 2 weeks prior to treatments.
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Photographs of the treatment are may be taken for my chart and future comparison. Complete confidentiality will be maintained.
(Client’s Initials)
The probability of success: Multiple treatments are needed, weeks or months. Six treatments are typical for Fitzpatrick Skin Types 1-3 and Eight Treatments are typical for Fitzpatrick Skin Types 4-6, but some people may require more. Hair loss may be permanently reduced after several treatments, but, not in all cases. Touch up treatment may be needed in the future. Results vary with the individual depending on skin color, hair color, and hair density. Recurrence of hair growth may occur at the treated site. I also understand some people do not respond to treatments.
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Loss of pigmented lesions such as freckles/moles may occur.
(Client’s Initials)
Test spots may be done to evaluate skin response prior to FULL treatment.
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Pre/Post treatment instructions. A printed copy of these instructions has been given to me and I understand them completely. I accept responsibility in complying with the treatment care instructions provided.
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For women of childbearing age: I am not pregnant. Furthermore, I agree to keep Atlanta Dermatology Consultants and staff informed should I become pregnant during the course of treatment.
(Client’s Initials)
Possible Risks/Complications with Laser Treatments:
- DISCOMFORT‐ Some mild discomfort may be experienced during laser treatments. The sensation of the laser is like a rubber band snapping against the Anesthesia is usually not necessary as the laser uses a cooling device that delivers a spray to the surface of the skin with the laser pulse is delivered. Numbing cream is available to control discomfort if necessary.
- BLISTERING/ BRUSING/REDNESS/SWELLING‐ Short term effects may include reddening, swelling, and mild burning which typically lasts 1‐3 days. Bruising, blistering, crusting or flaking may occur and require 1‐3 weeks to heal.
- INFECTION‐ Skin infection is a possibility although rare, whenever a skin procedure is performed. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with and without a past history of herpes simplex virus infections. Antiviral medication is recommended and is available by prescription. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
- PIGMENT CHANGES‐ Hyperpigmentation (darkening) and Hypopigmentation (lightening) of the skin have been noted after treatment. These conditions usually resolve within 3‐6 months, but permanent color change is a risk. Avoiding sun exposure before and after the treatment reduces the risk of color change. It is very important not to be tan (even minimally) when treated.
- SCARRING‐ However slight, there is a risk of scarring and skin textural changes. It is important that you follow all post treatment instructions carefully. Compliance is crucial for healing and prevention of scarring.
- BLEEDING‐ Protective eyewear will be provided. It is important to keep these goggles on that at all times during the treatment in order to protect your eyes from accidental laser exposure. I certify that I have read the above informed consent and fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. I consent to the terms of this agreement.
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