Laser Hair Removal Consultation/Consent Form | Aesthetics Forms Portal - Paperless Mission Control

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Full Body Laser Hair Removal Consultation & Consent

Notes:

Fill out form. If you have further questions or concerns after please indicate how you would like to be contacted; phone, text or a via Google Meet and best time to reach out. Thank you

Client Details

Name: *

Date of Birth: *

Contact Number: *

Email: *

Area(s) to be treated: *

Medical History

Are you currently (or possibly may be) pregnant? *

Many health care providers recommend avoiding laser hair removal during pregnancy because of the lack of information about the effect on the fetus.

Do you have any allergies or intolerances? *

Please specify: *

Have you been treated / taken medication for cancer within the last 6 months? *

Please specify/give details, including dates of medication/treatments *

Have you used Roaccutane, Isotretinoin or Retin-A within the last 6 months? *

Please specify/give details, including dates of medication/treatments *

Have you taken any anticoagulants (e.g. warfarin) or antiplatelet drugs (e.g. aspirin) within the last 6 months? *

Please specify/give details, including dates of medication/treatments *

Have you ever had a glycolic acid peel, chemical peel, microdermabrasion, or laser resurfacing? *

Are you prone to fever blisters / herpes? *

Please specify/give details: *

Have you ever experienced keloid scarring? *

Please specify/give details: *

Have you taken any antihistamines in the past week? *

Please specify/give details: *

Have you had any direct sun or sunbed exposure in the last 6 weeks? *

Please specify/give details: *

Have you plucked, waxed, or threaded the area(s) to be treated in the last 6 weeks? *

Please specify/give details: *

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Skin Care

Risks and Side effects

Please Note: Laser hair removal reduces and removal 80% or more depending on hair texture, and skin tone.

A few side effects can appear after laser hair removal. Most side effects are minor and temporary. Anyone experiencing lasting side effects should seek medical advice.

Common side effects:

Redness and irritation
Laser hair removal damages the follicles of the targeted hairs. The body reacts to this, and many people experience redness and irritation in the affected areas. The skin may tingle or feel tender, and may even appear to swell slightly.
The symptoms are usually short-lived. The affected area may look similar to skin that has just been waxed or plucked.
Irritation should ease after the initial reaction, usually within a few hours of the treatment. Swelling and redness may respond well to ice packs or a cool bath.

Crusting
Some people may experience skin crusting in the affected area. This is typically a minor issue but can be inconvenient.
Crusting can sometimes lead to scabbing or scarring. By taking care of the treated area after laser removal, such as by using a moisturizer, a person may prevent any lasting issues from this treatment.

Changes in skin color
Some people may notice minor color changes to the treated area of skin. It may get slightly darker or lighter, following laser hair removal.
People with lighter skin may be more likely to experience darker pigmentation changes. People with darker skin tones may be more prone to lighter pigmentation changes. These changes tend to fade away over time, and the skin returns to normal.

Eye injury
The hair removal procedure involves the use of powerful lasers. This means there is a risk of potentially serious eye injury, especially if the procedure is carried out on, or near, the face.
Both the person receiving the treatment and the practitioner should wear protective eye equipment to help prevent injury while the procedure is carried out.

Risk of skin infection
As with other cosmetic hair removal methods, damaging hair follicles with a laser can create an infection risk.
The affected area should be treated as a wound while it heals. Please seek medical advice for any sign(s) of infection.

Rare side effects / risks:

Burns and blisters
There is a low risk of burns and blisters as laser hair removal uses high-heat lasers.

Scars
Scars are typically not a side effect of laser hair removal, however it can sometimes occur. Scars may also form if you do not care for the treated area(s) correctly afterwards. The affected skin should be treated as if it had been sunburned to avoid further damage. This means keeping it moisturized, protected from light, and checked regularly for signs of infection.

Consent

It is important that you read the above information carefully and have all of your questions answered before signing the consent.

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above. *

Tap or click on the signature above to sign

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