First Time Laser

Informed Consent for Hair Removal

Customer’s name

Date

Treatment sites: mono-brow, lip, chin, neck, face, arms, fingers, chest, areola, linea, underarms, back, buttocks, bikini, labia, scrotum, thighs, lower legs, feet, and toes.

Combinations

Previous hair removal methods

(shaving, tweezing, waxing, depilatories, electrolysis, laser)

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 2-3 weeks.

Alternative methods are waxing, shaving, electrolysis, and chemical epilation.

The following problems may occur with the hair removal system.

However slight, there is a risk of scarring.
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.
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 individual 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 can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.
Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. Systematic reactions (which are more serious) may result from prescription medicines.
I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.
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.

ACKNOWLEDGEMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release

(individual) and

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release

(facility) and

(doctor) from all liabilities associated with the above indicated procedure.

Client/Guardian Signature

Date

Laser Technician Signature

Date

Post Treatment Instructions:

Immediately after the treatments, there should be redness and bumps at the treatment area, which may last up to 2 hours or longer. You should apply an ice pack, as there may be mild swelling. It is normal for the treated area to feel like sunburn for a few hours. Apply gloBarrier Balm to your skin at this time. You should use a cold compress if needed. Avoid any trauma to the skin for up to 2-5 days, such as bathing with very hot water, strenuous exercise, or massage.
Makeup may be used after the treatment has quit swelling unless there is epidermal bleeding or blistering. It is recommended to use new makeup to reduce the possibility of infection. Keep the area moist this will help the dead hair exfoliate from the follicle, so use moisturizer frequently and freely on the treated area. Any moisturizer without alpha-hydroxy acids will work.
Avoid direct sun exposure and tanning beds for 1-2 months and throughout the course of the treatment so as to reduce the chance of dark or light spots. Use SPF 30 sunscreen at all times throughout the treatment when going outside.
Avoid picking or scratching the treated skin. DO NOT USE any other hair removal methods or products on the treated area during the course of your laser treatments, as it will prevent you from achieving your best results.
You may shower after the laser treatments, and use soap, deodorant, etc. the treated area may be washed gently with a mild soap. Skin should be patted dry and NOT rubbed. You may apply deodorant after 24 hours.
Anywhere from 5-30 days after the treatment, shedding of the hair may occur and this may appear as new hair growth. This not new hair growth, but dead hair pushing its way out of the follicle. You can help the hair exfoliate by washing or wiping with a washcloth.
Hair re-growth occurs at different rates on different areas of the body. New hair growth will occur for at least three weeks after treatment.
Stubbles, representing hair being shed from the hair follicle, will appear within 10-20 days from the treatment date. This is normal and will fall out quickly.
Call our office at 703-726-8100 with any questions or concerns you may have after the treatment.

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MEDICAL HISTORY

OIL SECRETION

MOISTURE HYDRATION

CAPILLARY ACTIVITY

NERVE ACTIVITY

FEMALE CLIENTS ONLY

MALE CLIENTS ONLY

Informed Consent for Hair Removal

Post Treatment Instructions: