Client Consent for Laser Hair Reduction
Procedures: Laser Hair Reduction
Lasers: Quanta Alexandrite 755nm
Quanta Nd:YAG 1064nm
I hereby authorize and direct any associates or employees of Vasu, Inc to perform laser hair reduction on me. These treatments are only effective on actively growing hair. Multiple treatments are required to achieve cosmetically acceptable results. White, grey, red and blond hair will not respond to laser treatments. In rare cases, patients may not experience any hair reduction even with multiple laser treatments. I specifically acknowledge that no guarantees or warranties have been made concerning the results of the procedure.
The following points have been discussed with me and I understand: (please initial each statement)
The potential benefits of laser hair reduction.*
The most likely possible complications or risks involved with laser hair reduction include but are not limited to burns, blistering with infection and scaring, scabbing, herpes simplex virus activation, itching, red-purple discoloration, bruising and long-term pigmentary changes. Hypo-pigmentation or hyper-pigmentation could be permanent.
Blistering, infection, scarring, scabbing, bruising and long term pigmentary changes are more likely in people that are not honest about their tanning habits or who try to tan during their treatments. Tanned skin cannot be treated with the Alexandrite 755nm laser. I understand that it is my responsibility to let my technician know if I have received any tan throughout the course of my treatment.*
The presence of medical conditions that alter the hormone balance in females may limit the effectiveness of laser hair reduction.*
Close adherence to ideal laser schedules will improve your results. Conversely, failure to follow the laser schedule may diminish your results and in turn require more treatments than normal.*
Laser treatments tend to synchronize the growth cycle of hair; therefore, there may be the perception of increased hair growth during your treatments. This usually occurs near the third or fourth treatment. This is an ideal time to perform laser hair reduction due to the increased percentage of actively growing hairs that are the ideal targets for laser treatments.*
Topical anesthetic is not usually necessary as this laser uses a Zimmer Cryo 6 cooling device to reduce discomfort when the laser pulse is delivered. Topical anesthetic creams will reduce the discomfort in sensitive areas.
Eye protection must be worn at all times during the treatment.*
I hereby authorize Vasu, Inc or any associates to take pictures of the treated area to be used in my patient file and/or teaching purposes. I understand that the release of this information will be kept confidential and that no patient names will be used.*
I am not pregnant (female patients) and shall notify Vasu, Inc, if that changes.*
I have been given the opportunity to ask questions about the procedure(s). My questions have been answered and I understand the information given to me.*
Contraindications to the performance of this procedure(s) have been discussed in detail with me and I understand that my skin’s condition may actually temporarily worsen as a result of this treatment.*
I recognize that the practice of laser medicine is not an exact science and acknowledge that no guarantees have been made to me concerning the results of such procedures and thus no monetary refunds will be issued to me on any previous or future treatments.*
I understand that immediately following the laser treatment, the treated area will appear as a red discoloration and have edema (swelling). The redness (erythema) and discoloration may take up to 6 months to heal. The treated area will feel like a sunburn for a few hours after treatment.*
I received the after care instructions for laser hair reduction.*
I understand that I shall not spray tan, use self tanning lotions and sun tan during my treatments. The sun and tanning lotions are a competing chromophore for the laser.*
I understand and agree to give at least 24-hour cancellation or re-scheduling notice and I agree to pay a minimum of $50.00 or forfeit my treatment if I don’t give proper notification.appointments.*
I understand that I release Vasu, Inc and its associates, the Medical Director, the laser technician performing the procedures and any other person involved in my treatment from any liability associated with complications from the laser procedure. By my signature below, I certify that I have read and fully understand the contents of this permission and authorize the performance of laser hair reduction by the staff of Vasu, Inc.
(PURSUANT TO 45 CFR 164.508)
“This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.”
Vasu Skin Solutions is dedicated to protecting the private and medical information of our patients.
It is our firm policy not to share any client information without written permission from the client. Below is a brief summary of our policy and disclosure permission form. If you already have someone in mind that might need access to your medical records, please list that person below.
Vasu’s, policy was put in place to protect your “protected health information” or “PHI”. Therefore we will not discuss any information with you, or anyone else, without first verifying your identity by date of birth, address and getting your written permission to do so.
Your PHI will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers if desired, laboratories and health insurance payers as it necessary and appropriate for your care. Your signature below indicates that you understand and accept Vasu, Inc’s privacy policies. The full description go our privacy policies are located here: www.vasuskinsolutions.com/about-vasu/policies
Release of Information (Check the appropriate boxes and complete the requested information)
* I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:
Information is not to be released to anyone except self.
This Release of Information will remain in effect until terminated by me in writing.
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