Laser Skin Tightening YAG-1064 Safety Questionnaire and Consent Renewal
The following questions are required to ensure the safety and efficacy of the laser treatment. All questions pertain solely to the area being treated. For 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
NOYES In the last 4 weeks, have you had any waxing, tweezing or threading?
NOYES In the last 4 weeks, have you experienced prolonged unprotected sun exposure?
NOYES In the last 2 weeks, have you applied any self-tanner or bronzing products?
NOYES In the last 2 weeks, have you taken any medications that make you sensitive to the sun? Common examples: Antibiotics, diuretics, antifungals, acne medications and St. John’s Wart.
NOYESN/A Are you currently pregnant or nursing?
NOYES Pacemaker or Defibrillator?
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 reduction 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 Skin Tightening YAG-1064 Safety Questionnaire and Consent Renewal
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