New page | Luxury Skin

Laser Light Consent Form.

First name

Last name

Phone

Birthday

Day

Month

Year

Emergency Contact

Date

Day

Month

Year

Please list all medications that you take regularly, including hormones, vitamins, etc

Details:

Is there a family history of superfluous (excess) hair?

Yes

Do you have any allergies? If so, please disclose any allergies.

Are you currently under doctors care?

Yes

Details:

Do you smoke or Vape or use e-cigarettes? If so, how many per day?

Yes

Details:

Are you on hormone replacement therapy?

Yes

Details:

Do you have permanent makeup or implants in the treatment area?

Yes

Details:

Have you got ANY type of skin tan (fake or natural/sun exposure)

Yes

Details:

Skin type analysis How would you rate your skin in the area being treated?

Type 1 - always burns, never tans, extremely fair skin/blonde hair/blue/green eyes.

Type 2 - usually Burns, tans less than average. Fair skin, sandy brown to brown hair, green/blue eyes.

Type 3 - sometimes bands gradually tan to an average medium skin tone, brown hair, green/brown eyes.

Type 4 - sometimes burns; tans light brown or olive; skin dark brown; eyes and hair.

Type 5 - rarely burns, tans profusely, dark brown skin, black hair, black/ dark brown eyes.

Type 6 - deeply pigmented, never burns black skin, black hair, dark brown/black eyes.

I consent and authorise Luxury Skin clinics to perform laser light treatment on me. I understand the following points and have had the opportunity to ask questions during my consultation.

In relation to my laser treatment, I have been advised as follows:

Treatment is successful on most clients, but my individual results cannot be guaranteed.
Most clients require 8 – 10 treatments to achieve up to 80% hair reduction; some may require more. Hair loss is variable, and individual results depend on many factors, thus it is extremely difficult to advise on the exact number of treatments required.
Blonde and red hair will have some reduction, however, not same as black hair, no guarantee for grey hair.
Fine facial hair takes longer to respond to treatment than hair in other areas and will require additional treatments.
Darker skin type clients will require additional treatments.
Exposure to UV Rays will compromise my treatment, therefore I will use SPF 30+ sunscreen.
Growth of dormant follicles that may be triggered by hormonal changes (e.g. stress, illness, medications, pregnancy, trauma or other causes) can stimulate future hair growth.
Not following the program regarding the timing of treatments will reduce the efficacy of my treatment.

In relation to laser photo-rejuvenation treatments, I have been advised as follows:

Treatment is successful on most clients, but my individual results cannot be guaranteed.
Most clients will require 4 treatments for successful reduction of pigmentation/capillaries, and results are variable.
Darker pigmentation responds better to treatment than lighter pigmentation, and micro-crusting will occur.
Exposure to UV Rays will cause pigmentation to darken again; skin care is essential.
Vascular lesions may reappear within 7 days after treatment, whilst the capillary is still compromised, further treatment is highly recommended within 14 days; failure to do so will reduce the efficacy of treatment.

Risks associated with laser treatments (hair removal and photo-rejuvenation). Even though the risk of complication is extremely low, the following can occur: (Please tick)

Pigment changes (light or dark spots on the skin) lasting 1 – 6 months. Freckles may temporarily or permanently disappear in treated areas. Other potential risk includes crusting, itching, pain, bruising, pimple-like bumps, dry skin, hypopigmentation (lightening of the skin), hyperpigmentation (darkening of the skin), blistering, burns, infection, scabbing, swelling, a very small risk of scarring and a failure to achieve the desired result.

Allergic or delayed inflammatory reactions can develop. A test patch is performed to ascertain reaction of the skin to IPL/laser.

Laser light systems can cause eye injury and protective eyewear must be worn during treatment.

Prior to initiation of treatment, any pigmented lesions should be correctly identified by a physician to be benign and recommended for light-based treatment. A medical certificate to this effect is required.

I consent to photographs taken to evaluate effectiveness. Photographs revealing my identity will not be used without consent.

I understand the sensation of light-based treatments is sometimes uncomfortable and feels like a flicking sensation.

I am aged 18 years or over

I will advise Luxury Skin Clinics of any changes that occur during my treatment that can increase potential risks or reduce efficacy.

I also understand that there will be no refund for any performed services.

In relation to my initial and all subsequent treatments I advise that: (Please tick)

I have not had unprotected sun exposure (including tanning beds and fake tan) in the last four weeks.

I have no history of seizures and I have disclosed all known allergies.

I'm not taking medications causing photo sensitivity.

I do not have a history of keloid or hypertrophic scar formation.

I do not have active infections/immunosuppression.

I do not have open lesions in area being treated.

I do not have herpes type one or two in the area being treated.

I have not used tretinoin (Retin- A, Renova) within the last 2 weeks.

I have not had laser resurfacing within the last 6 months.

I have not had a chemical peel within the last 4 weeks.

I have advised my technician if I am diabetic.

I am not pregnant.

I have not used oral isotretinoin or Accutane within the last 6 months.

I have received the pre-and post care information. I agree to adhere to all these recommendations.

I acknowledge the 24-hour cancellation policy and acknowledge that all deposits will be kept if this appointment is no showed cancelled or rescheduled within the 24 hours.

I have read all of the above and had all my questions satisfactorily answered. NOTE: Do not sign this form until you have read and understood all above.

Date

Day

Month

Year

Client Signature approving all information above:

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.