Laser Hair Removal/Reduction - Patient consent & Fitzpatrick Skin Type


The purpose laser hair reduction is to diminish or remove unwanted hair from most areas of the body. The procedure requires more than one treatment and may produce permanent hair reduction. The total number of treatments will vary between individuals. On occasion, there are those that do not respond to treatments. The treated hair should exfoliate or push out in approximately 2-3 weeks.

The following risks may occur with treatment. However slight, there is a risk of scarring, pain, bruising, swelling, redness, itching, skin inflammation or irritation (dermatitis), allergic reaction, blistering, hypopigmentation, hyperpigmentation, mottling of skin vascularity and pigmentation, and other unforeseen complications. These conditions usually resolve in 3-6 months, but permanent color change is a risk. Avoiding sun exposure before and after the treatment reduces this risk. 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 infections occur, additional treatments or medical antibiotics may be necessary.

Other risks include the following: Pinpoint bleeding is rare but can occur following treatment procedures. In rare cases, local allergies to topical preparations have been reported. Systemic reactions, which are more serious, may result from prescription medicines. I understand that exposures of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times during treatment.

Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and pigment changes. 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.

I have read and understood  the risks of treatment, the expected benefits, and alternative options, including no treatment at all. I understand that every effort will be made to provide a positive outcome, but there are no guarantees of results. I understand and accept the risks of the procedure, and request that it be performed on me. I hereby release the medical director, esthetician, and facility from liability associated with this procedure. I consent to this procedure today and for all subsequent treatments.

 

 

Fitzpatrick Skin Type Form

What is your Ethnicity?  

Score 0 1 2 3 4
What is your eye color? Light Blue, Gray, green Blue-Gray, green Blue Dark Brown Brownish Black
What is the natural color of your hair Sandy Red Blond Chesnut/Dark Blond Dark Brown Black
What is the color of your skin(non- exposed areas)? Reddish Very Pale Pale with Beige Tint Light Brown Dark Brown
Do you have freckles on unexposed areas? Many Several Few Incidental None

 

Please total your score for Genetic Disposition:

 

Score 0 1 2 3 4
What happens when you stay too long in the sun? Painful redness, blistering, peeling Blistering, followed by peeling Burns sometimes followed by peeling Rare burns Never had burns
To what degree do you turn brown? Hardly or not at all Light color tan Reasonable tan Tan very easy Turn dark brown quickly
Do you turn brown within several hours of exposure? Never Seldom Sometimes Often Always
How does your face react to the sun? Very Sensitive Sensitive Normal Very Resistant Never had a problem

 

Please total your score for Sun Exposure:

 

Score 0 1 2 3 4
When did you last expose your body to the sun (or tanning bed/tanning cream? More than 3 months ago 2-3 months ago 1-2 months ago Less than a month ago  Less than 2 weeks ago
Did you expose the are to be treated to the sun? Never  Hardly Ever  Sometimes Often Always

Please total your score for Tanning Habits:

Your Fitzpatrick Skin Type:

Skin Type Score Fitzpatrick Skin Type
0-7 I
8-16 II
17-24 III
25-30 IV
Over 30 V

 

The following questions are required to ensure the safety and efficacy of the laser treatment. All questions pertain solely to the area being treated. Example: if you recently had a chemical peel on your face and are having laser hair removal on the underarms today you would check ‘no’ as the chemical peel was not performed on the area being treated.

  In the last 72 hours have you had any clinical peeling procedure done? 

  In the last 72 hours have you used any acid based products (salicylic, glycolic, etc.)?    

  In the last 72 hours have you used any retinol based products?*   

  In the last four weeks have you had any waxing, tweezing or threading?

  In the last 4 weeks have you had regular sun exposure or tanning?  

  In the last 4 weeks have you applied any self-tanner or bronzing products?  

  Are you currently using any medications that make you sensitive to the sun?*  Common examples: Antibiotics, diuretics, antifungals, acne medications and St. John’s Wart   

  Are you currently pregnant or nursing?    

  Pacemaker or Defibrillator?  

*Please check with your treatment provider if you are unsure if a medication or supplement you are using might compromise the safety and efficacy or your treatment.

I acknowledge that all information contributed by me is true and accurate to the best of my knowledge.  I will inform my skin care professional if there are any changes to my medications, recent prolonged sun exposure or topical bronzing usage, or any new contraindications for the treatments outlined in my treatment plan.  I will immediately contact the facility if any adverse reactions appear following the procedure. I have been advised of the contraindications for laser hair removal and understand that with any laser treatment there are associated risks such as burns and blisters that may result in scarring of the skin. I consent to the treatment described above with its associated risks. I hereby release the medical director, esthetician and the facility from liability associated with this procedure.

  Date:

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Document name: Laser Hair Removal/Reduction - Patient consent & Fitzpatrick Skin Type
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May 14, 2020 12:58 pm PSTLaser Hair Removal/Reduction - Patient consent & Fitzpatrick Skin Type Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 67.183.34.85