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

 

Leave this empty:

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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 PDTLaser Hair Removal/Reduction - Patient consent & Fitzpatrick Skin Type Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 173.160.193.254