Laser hair removal Consent Forms Step 1Step 2Step 3Laser Hair Removal Consent Form I understand that a $30.00/$60 dollar fee will be charged if I do not cancel or reschedule my appointment within 24 hours in advance.Balances will automatically be charged to your account. *AgreeI do understand that TAXES and GRATUITY are not included. *AgreeFirst Name *Last Name *Date / Time *Date of Birth *Address *Address Line 1CityState / Province / RegionZip / Postal CodePhone *Email *Emergency Contact Name Emergency Phone Number Which of the following best describes your skin type: Always burns, never tansAlways burns, sometimes tansSometimes burns, always tansRarely burns, always tansBrown or Black, Pig-mated SkinMedical HistoryAre you currently under the care of a physician? YesNoIf yes, for what? Are you currently under the care of a dermatologist? YesNoIf yes, for what? Do you have any of the following medical conditions? CancerDiabetesHigh Blood PressureHerpesFrequent Cold SoresHIV/AIDSKeloids ScarringSkin Disease/Skin LeisonsSeizuresHepatitisHormone ImbalancesOtherIf Other, please list: MedicationsAre you taking oral medications presently? YesNoOtherIf Other, please list: Have you ever used Accutane? YesNoIf yes, when did you last use it? What topical medications or creams are you currently using? Retinoids (Retin-A)OtherNoneIf Other, please list: HistoryHave you ever had laser hair removal? YesNoHave you performed any of the following hair removal methods in the past six weeks? ShavingWaxingElectrolysisTweezingDepilatoriesOtherIf Other, please list: Have you been tanning or had recent sun exposure that changed the color of your skin? YesNoHave you recently used any self-tanning lotions or treatments? YesNoDo you form thick or raised scars from cuts or burns? YesNoFor our female clients:Are you pregnant or trying to become pregnant? YesNoAre you breastfeeding? YesNoI certify that the medical, personal and skin history statements I have provided are true and correct. I am aware that it’s my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. I duly authorized Step Up Skin Laser LLC to perform the Inova Diode Laser Hair Removal procedure and any other measures which in their option may be necessary. I understand that the Inova Diode Laser Hair Removal System is intended for hair removal and that clinical results may vary with different skin types, hair color and location on the body. I understand there is a possibility of rare side effects such as scarring and permanent discoloration as well as short-term effects such as redness, mild burning, blistering, temporary bruising and temporary discoloration of the skin including hyperpigmentation (decrease in skin pigment) or hyperpigmentation (increase in skin pigment). These effects have been fully explained to me. I understand that to achieve maximum results the protocol prescribed should be adhered to. The treatment schedule is designed to maximize the results during treatment of each hair cycle. If for any reason the schedule cannot be adhered to, I understand that the total percentage of hair loss could be affected. In addition, hair follicles that are dormant now may become active during or after my treatments may be necessary. I also understand that I will have to pay for these additional treatments. I understand that treatment by Inova Diode Laser Hair Removal System involves a series of treatments and the fee structure has been fully explained to me. I certify that I have been fully informed of the purpose of the procedure, expected outcomes and possible complications. I understand that no guarantee can be given as to the final results obtained. I am fully aware that my condition is a cosmetic concern and that decision to proceed is based solely on my expressed desire to do so. I confirm that I am not pregnant at this time and that I have not taken Accutane within the last 6 months. I do not have a pacemaker or internal defibrillator. I understand I need to stop tweezing, waxing, bleaching, using depilatories or any substance/medication that will damage the hair within the follicle. I understand that I need to shave, trim, clip, or cut any of the surface hairs before I have a treatment done. I understand that Step Up Skin Laser LLC is not responsible for any tattoo damages. I understand excessive sun exposure needs to be avoided prior to treatment. For optimal results, I should attempt to maintain the same skin tone throughout the treatment process. Sun exposure, tanning bed exposure,or the use of tanning creams could result in a less effective treatment. I have read and understand this agreement and all my questions have been addressed and answered to my satisfaction. I understand the purpose of this procedure is to remove unwanted hair. There are several alternatives to laser hair removal treatment including electrolysis, shaving, waxing and tweezing. Unprotected sun exposure following treatments is contraindicated as it may cause or worsen this condition. I have been asked at this time whether I have any questions about this procedure. I understand the procedure, the risks, I accept this procedure to be performed on me by the doctor or other qualified individuals. AgreeI am aware that I cannot get hair laser removal under any medication without disclosing it to my technician. AgreeI understand that I cannot get treated if I have used ACCUTANE within the last 6 months. AgreeI understand that I have disclosed all tattoos & I have to cover them before my procedure AgreeI understand that I need to shave the areas a day before the treatment AgreeI am aware that I have to stop waxing, bleaching, threading, plucking, tanning, depilatory creams, epilator,scrubs, peelings, microdermabrasion 3 weeks prior to my treatment. AgreeI am aware that I cannot perform any physical activities that increase my body temperature or blood pressure immediately before & after my treatment AgreeClient Name *Date: *Signature * CommentPreviousNextSubmit
