Laser Hair Removal/Reduction - Patient Consent
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?
Please total your score for Genetic Disposition: SCORE012345678910111213141516
Please total your score for Sun Exposure: SCORE012345678910111213141516
Please total your score for Tanning Habits: SCORE012345678
Your Fitzpatrick Skin Type:
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.
NOYES In the last 72 hours have you had any clinical peeling procedure done?
NOYES In the last 72 hours have you used any acid based products (salicylic, glycolic, etc.)?
NOYES In the last 72 hours have you used any retinol based products?*
NOYES In the last four weeks have you had any waxing, tweezing or threading?
NOYES In the last 4 weeks have you had regular sun exposure or tanning?
NOYES In the last 4 weeks have you applied any self-tanner or bronzing products?
NOYES 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
NOYES Are you currently pregnant or nursing?
NOYES 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.
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Document Name: Laser Hair Removal/Reduction - Patient Consent
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