Laser Hair Removal and Acne Treatment Consent Form

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Laser Hair Removal and Acne Treatment Consent Form

First Name

Email

Last Name

Address

Phone Number

Appointment's Date

Do any of the following pertain to you? Please check mark if applicable * Required

Tetracycline/ Minocylcine

Do you bruise easily

Do you have any history of seizure or convulsions?

Are you on Phenobarbital

Are you on any medications? If so please specify in the comments section below

Allergies

Bruise easily

Eczema

Herpes

Keloids

Irregular pigmented moles

Pregnancy

Acne? Have you have been on Accutane/topical acne medications

Cancer? If so please specify in the comments section below

Diabetes?

Do you or have you waxed in the past? If so please specify when in comment section below

Warts

Recent sun exposure/ UVR tanning bed (wait 3-8 weeks before procedure and 2 weeks post)

PCOS (Polycystic Ovarian Syndrome)

Thyroid Disorder

Currently under the care of a physician?

Laser Procedures

Tattoos (or permanent makeup) on or near the treatment area?

None of Above

Comments

I understand that hair removal and laser skin rejuvenation vary widely from person to person and anatomical area to area. 70-80% of hair is estimated to be reduced after a series of treatments but there is a chance I could be a non-responder

I understand multiple treatments may be necessary for best results

I understand that with all laser or IPL treatments there is a possibility of a contraindications that may cause a burn

I understand that there may be some temporary swelling and/or redness in the treated area

If treatment is performed near a tattoo, I understand that the tattoo (or permanent make up) maybe damaged during the treatment.

I acknowledge that I must reveal any condition that may have a bearing on this procedure, such as pregnancy, allergies, medications used, diabetes, immune deficiencies, seizures, history of cancer prior to receiving treatment

I acknowledge that there may be some slight lightening or darkening of the skin in the treatment area. This will generally go away within few weeks to months.

I acknowledge that my skin might experience temporary tightness or redness (a mild sunburn feeling) which usually dissipates within 24 hours depending on skin sensitivity.

I acknowledge that if I fail to use adequate sunscreen (SPF 30), I am more susceptible to sunburn and skin damage

I acknowledge that 1 should avoid use of glycolic or Retinoic acid, AHA products for 2-4 days before and after treatment

I will not use any hair removal creams or bleach, nor wax or thread between treatments. I can shave between treatments.

I understand that laser follow up appointments are 4-8 weeks apart depending upon my hair growth cycle and 3-6 weeks apart for skin rejuvenation.

I acknowledge this is a strictly elective cosmetic treatment but I must protect the treatment area from the sun 3-8 weeks prior to the procedure and 2 weeks post procedure to prevent burning and hyper and hypo-pigmentation. No medical claims expressed or implied

I will notify any change in medical health since my last visit

I will be off photosensitive drugs, such as antibiotics 2 weeks prior to my treatment

By Signing below, I verify that I have read and understand the above statements and agree to them.

Do you allow us to take before and after pictures for us to display on our website or any social media websites

Your Signature

Contact Us

519-939-9318

blinksbrowsboutique@gmail.com

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5 First St unit 3, Orangeville, ON L9W 1E1, Canada

Laser Hair Removal and Acne Treatment Consent Form

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