Laser Hair Removal Consent
Please read carefully and initial:
I have not used retin-A for 72 hours
I do not have any active cold sores.
I acknowledge that there is a rare possibility of an allergic reaction. I have previously used alphahydroxy acid products on my skin and/or in the past with no allergic reaction, but understand there still could be a response.
I agree to avoid direct sun exposure for 48 hours.
I agree to notify my esthetician of any concerns.
I agree not to wax for 72 hours pre/post treatment.
There will be a $50 charge for patients who aren't shaved and need shaving. Your appointment may have to be rescheduled if you do not come shaved and our schedule does not allow enough time to perform your treatment.
We have a 24-hour cancellation policy. You will be changed full price for all appointments that are a no show and $25 for appointments that are cancelled in less than the 24 hour period. You must have a credit card on file at all times while receiving treatments at Blue Divine due to this cancellation policy. No refunds.
Informed Consent for Hair Removal
Treatment sites: (please check all that apply)
Previous hair removal methods:
The purpose of this procedure is to diminish or remove unwanted hair. The procedure requires more than one treatment and may produce permanent hair removal. The total number of treatments will vary between individuals. On occasion there are patients that do not respond to treatments. The treated hair should exfoliate or push out in approximately 2-3weeks.
Alternative methods are waxing, shaving, electrolysis, and chemical epilation.
The following problems may occur with the hair removal system:
1. There is a risk of scarring.
2. Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation (browning) and Hypo-pigmentation (lightening) have also been noted after treatment. These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Avoiding sun exposure before and after the treatment reduces the risk of color change.
3. Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
4. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.
5. Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. Systemic reactions (which are more serious) may result from prescription medicines.
6. I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.
7. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.
Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.
We have a 24 hour cancelation policy. You will be changed full price for all appointments that are a no show.
My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release Blue Divine Aesthetics Staff, and specific technicians from all liabilities associated with the above indicated procedure.