CLIENT INFORMATION & MEDICAL HISTORY
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire.
All information is strictly confidential.
*Do you regularly sun bathe or use tanning salons?
If Yes, how Often?
*Are you currently under the care of a physician?
Do you have any health problems or medical conditions? Please list:
*Have you ever had an allergic reaction?
If Yes, list any and all that you have had describe the reaction you experienced
What oral prescription medications are you presently taking?
Others (It is required that you list all of them)
What antibiotics do you use to treat infections?
*Do you take any medications for heart conditions?
*Are you on any mood altering or anti-depression medication?
What topical medications or creams are you currently using? (RetinA or others)
What herbal supplements do you use regularly?
For our female clients:
*Are you pregnant or trying to become pregnant?
*Are you breastfeeding?
*Are you using contraception?
I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professional of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
Client or Parent/Legal Guardian Signature - Use your mouse or finer to draw your signature below:
LASER HAIR REMOVAL
New Client Consult Consent Form
Client or Parent/Legal Guardian Name:
- I understand that I cannot be on antibiotics or any photosensitive medication for two weeks prior to my laser appointments. If so, I will be required to reschedule my appointment.
- I understand that stubble or any unshaven hair will reduce my hair will reduce my hair reduction and that I am expected to arrive appointment shaven.
- I understand that there is a 24-hour-cancellation policy. I understand that I will be charged a fee of 30 dollars if I miss an appointment.
- I understand that packages may not be broken up into separate visits.
- I understand that the laser can burn and fade my tattoos or permanent make-up and that it is my responsibility to each treatment to alert the aesthetician as to the location of all my tattoos or permanent make-up. I understand there is a risk of my tattoos or permanent make-up fading even if the laser does not directly touch the tattoo or permanent make-up. I understand that if one, or any of my tattoos or permanent make-up. I understand that if one, or any of my tattoos or permanent make-up is faded or damaged, it is my responsibility to cover any costs to correct the damage.
- I understand that I cannot have a recent sunburn (within 7 days) or have on self-tanner (within 7 days) when I come in for my laser appointment.
- I understand that exposure of my eyes to laser light could harm my vision. I will keep the eye protection provided on at all times.
- I understand that compliance with the pre-care and aftercare instructions is crucial for healing, prevention of scarring, and hyper / hypo-pigmentation.
- I understand that a laser is effective by heating the hair forcible. The heat from the laser may cause burns, blisters, hypopigmentation, scars, skin swelling or itching to the treated or surrounding areas. I will call the office within the first 12 hours of these symptoms for instruction on how to best treat each symptom.
- I understand that from time to time one of my appointments may be cancelled because of technical problems with a laser and my appointment will be rescheduled as quickly as possible.
- I understand that hyper and hypo pigmentation is possible.
- I understand that the treated area may take 3-6 months to heal.
I understand that there are risks associated with laser hair removal and these include, but are not limited to:
- A risk of scarring and or burning.
- Short term reddening, mild burning, temporary bruising, blistering, hyper-pigmentation (browning), and hypo-pigmentation (lightening). 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 to the skin.
- 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.
- Bleeding: Pinpoint bleeding is rare but may occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.
- Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetic or topical preparations have been reported. Systemic reactions (which are more serious) may result from prescription medicines.
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.
I clearly understand all the above risks with any later procedure. It is my responsibility to notify the aesthetician if I do not understand a risk risks or have any questions with the procedure. I hereby release all aestheticians, employees and Laser Logic from any and all liabilities associated with the laser hair removal, skin rejuvenation, or any laser procedure.
Client or Parent/Legal Guardian Signature:
LASER HAIR REMOVAL
Pre and Post Treatment Instructions
- No tweezing, bleaching or waxing to the area to be treated for a minimum of six weeks prior to treatment. Alternative methods of hair management during this time are shaving with a razor or electric clippers.
- Avoid sun exposure, tanning beds and self-tanning creams that dye the skin for a minimum of two weeks prior to treatment, and throughout the course of treatments.
- If treating the facial area, refrain from using Retin-A, AHA’s and BHAs for 48 hours prior to treatment.
- Shave area to be treated prior to each appointment.
- If you are susceptible to cold sores or have genital herpes, start taking Zovirax or similar medicine before treatment.
I understand the pre-treatment instructions.
- After treatment, you may have redness or bumps. This is a common occurrence with laser hair removal. You may use a cold compress or aloe gel as needed.
- Avoid saunas, hot tubs, excessively hot baths and showers for 24 hours after treatment.
- Avoid sun exposure for a minimum of 24 hours after treatment AND for as long as the redness in the treated area remains.
- If the facial area was treated, refrain from using Retin-A, AHA’s and BHA’s for 48 hours after treatment to avoid irritation.
- If you experience itching in the area treated, apply 1% hydrocortisone cream and/or and antihistamine (Claritin, Benadryl).
- Make-up may be used as normal.
- Use sun block with SPF 30 or more for two weeks after treatment.
- Besides your laser treatment, the only other acceptable hair removal method during your treatment regimen is shaving trimming, as needed.
- Hair in the treated area will shed for up to three weeks after treatment. While this may like new hair growth, it is actually destroyed hair and follicles. You may help this process by gently using a “loofah” or washcloth.
I understand the post-treatment instructions.