Laser hair removal Consent Forms

Laser 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.

Field is required!
Field is required!
Balances will automatically be charged to your account.
Field is required!
Field is required!
I do understand that TAXES and GRATUITY are not included.
Field is required!
Field is required!
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.
Field is required!
Field is required!

Personal History

Field is required!
Field is required!
Date
Field is required!
Field is required!
Date Of Birth
Field is required!
Field is required!
Address
Field is required!
Field is required!
Phone Number
Field is required!
Field is required!
Emergency Contact Name
Field is required!
Field is required!
E-mail address:
Field is required!
Field is required!
Emergency Contact Number
Field is required!
Field is required!
Field is required!
Field is required!
Which of the following best describes your skin type:
Field is required!
Field is required!

Medical History

Are you currently under the care of a physician?
Field is required!
Field is required!
If yes, for what?
Field is required!
Field is required!
Are you currently under the care of a dermatologist?
Field is required!
Field is required!
If yes, for what?
Field is required!
Field is required!
Do you have any of the following medical conditions?
Field is required!
Field is required!
If Other, please list:
Field is required!
Field is required!

Medications

Are you taking oral medications presently?
Field is required!
Field is required!
If Other, please list:
Field is required!
Field is required!
Have you ever used Accutane?
Field is required!
Field is required!
If yes, when did you last use it?
Field is required!
Field is required!
What topical medications or creams are you currently using?
Field is required!
Field is required!
If Other, please list:
Field is required!
Field is required!

History

Have you ever had laser hair removal?
Field is required!
Field is required!
Have you performed any of the following hair removal methods in the past six weeks?
Field is required!
Field is required!
If Other, please list:
Field is required!
Field is required!
Have you been tanning or had recent sun exposure that changed the color of your skin?
Field is required!
Field is required!
Have you recently used any self-tanning lotions or treatments?
Field is required!
Field is required!
Do you form thick or raised scars from cuts or burns?
Field is required!
Field is required!

For our female clients:

Are you pregnant or trying to become pregnant?
Field is required!
Field is required!
Are you breastfeeding?
Field is required!
Field is required!
I 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.
Field is required!
Field is required!
I am aware that I cannot get hair laser removal under any medication without disclosing it to my technician.
Field is required!
Field is required!
I understand that I cannot get treated if I have used ACCUTANE within the last 6 months.
Field is required!
Field is required!
I understand that I have disclosed all tattoos & I have to cover them before my procedure
Field is required!
Field is required!
I understand that I need to shave the areas a day before the treatment
Field is required!
Field is required!
I am aware that I have to stop waxing, bleaching, threading, plucking, tanning, depilatory creams, epilator,scrubs, peelings, microdermabrasion 3 weeks prior to my treatment.
Field is required!
Field is required!
I am aware that I cannot perform any physical activities that increase my body temperature or blood pressure immediately before & after my treatment
Field is required!
Field is required!
All patients are required to complete a consultation prior to getting treated. This will give you time to explain treatment information & answer questions you may have.
Credit Card information
Credit Card information is encrypted and confidentially stored to your account.
Please Sign
Field is required!
Field is required!
Field is required!
Field is required!
Date
Field is required!
Field is required!