GENERAL LASER CONSENT FORM
HAIR REDUCTION, VASCULAR TREATMENT AND LASER SKIN TREATMENT
Prior to receiving my treatments: I understand the goal of any Laser procedure on the Face, Body and Private area is a cosmetic
procedure, is improvement, not perfection. I understand that my results may not be perfect and there is possibility of side effects
and General risks.
Procedures:
Enhanced Skin Rejuvenation, Wrinkle Reduction, Vascular & Pigmented Lesions can be performed by Carbon Laser,
Erbium YAG laser or Diode Mediostar System, Tattoo Removal
A laser treatment is a technique used to improve skin texture and eliminate blemished areas or tattoo inks (black and red only) from
the skin. It is useful to counteract aging and sun damaged skin. The laser is designed to penetrate the lower layers of the skin with
minimal injury to the outer layers for tattoo removal or Erbium Yag . Benefits include: reduction of fine wrinkles, pigmented lesions,
solar spots, uneven skin color, and small red or blue vessels may be reduced or eliminated.
Permanent Hair Reduction & Pseudo folliculitis
Designed to target or destroy the hair follicle. Benefits include: delayed hair regrowth in the treated area, lightening of the hair,
decreased density of the hair, and long term hair reduction. Multiple treatments will be needed to achieve satisfaction. You should not
expect the treated areas to be completely hair off.
Acne Treatment
A laser treatment used to treat acne lesions on any part of the body. The laser penetrates the lower layers of the skin with minimal
injury of the outer layers to reduce acne. Multiple treatments will be needed to reduce acne and the severity of lesions.
RISKS AND CONTRAINDICATIONS:
Laser treatment can present an eye hazard. To protect against damage and discomfort, you are required to wear protective eyewear,
which we provide, that have been designed and tested specifically for this use.
Risks and side effects may include: bruising, temporary pain and itching, redness, infection, onset of herpes, onset of acne,
burning and blistering, unsatisfactory cosmetic result, extrusion, swelling, allergic reaction, dryness, tiny scabs, flaking, crusting,
hair reduction, skin discoloration (hyper and hypo pigmentation, which can be temporary), scar formation and superficial
temporary dark spots may occur after the procedures. Picking the area may result in adverse reactions and affect the results of the
treatments thereby strictly prohibited.
A topical anesthetic may be applied before treatments to help alleviate some of these discomforts. Multiple treatments will be necessary
to achieve complete satisfaction. There is no guarantee, either expressed or implied as to the success or other any result of the procedure.
If there is any untoward reaction to the skin call the Doctor immediately and Inform your therapist (Clinic).
ALTERNATIVES TO LASER HAIR REMOVAL
There are several alternative treatments to laser therapy. These include electrolysis, tweezing, waxing and shaving.
By signing this form, I confirm and consent to the following:
1. I have not had any chemical peel of any kind (laser or other cosmetics procedures), within14 (may variety) days prior the
treatment. I understand I cannot have another treatment within 14days (may variety) after my treatment whether it is performed at
this location or any other location.
2. I have been truthful in revealing any condition that may be contraindicated to this procedure, such as: pregnancy (if so, consult
your physician prior to treatment), recent facial surgery, allergies (especially on vit. A retinol, vit C, antibiotics and etc..), tendency
to cold sores/ fever blisters, use of Retin-A, Accutane (for the last 6 month), birth control pills, androgens, minoxidil, steroids,
Haldol, phenytoin, Thyroid medication or any other medical prescriptions, history of melanoma, cancer, keloid scar formation,
healing problems, active infections, tattoos (henna), autoimmune disease, skin and other disorders. In case, that I have known and
unknown cases of such contraindication and would like to proceed with the procedure, I will be solely responsible for the
consequence of the treatment.
3. I have not received any type of hair removal except for simple shaving for the past 14 days.
4. I understand that waxing, tweezing, plucking, depilatories, electrolysis or other laser hair removal should be avoided– as it
can affect the results.
5. I have not had any sun exposure for the last month or self-tanning. I understand that extended direct sun exposure is
prohibited while am undergoing treatment and the daily use of sunscreen protection with a minimum of SPF 30+ is
mandatory.
6. I understand I must use sunblock and homecare product regularly after my treatments and avoid direct sun during my
treatment period
7. Lasers are not intended for pregnancy or breastfeeding, it is patients responsibility to inform the practitioner prior to beginning of the
treatment.
I declare that I have read the entire above Informed Consent and was adequately explained the risks of this therapy, alternative
methods of treatment, and possible benefits from this treatment, and I hereby consent to the laser treatment to be performed to me.
Considering that I have been informed that certain medical conditions and medications prohibit the patient from laser therapy, I have
provided a full and truthful medical history and a truthful and accurate account of my medications to this clinic.
I agree that if I should have any questions or concerns regarding my treatment/results I will notifyimmediately so that timely follow-
up and intervention can be provided.
Having been apprised of all the above, I have signed this Consent Form and authorize the subject treatment.
Patient Full Name & Signature: __________________________ Date & Time: ___________________
Therapist Name & Signature: ____________________________ Date & Time: ___________________
