HAVE YOU EVER HAD ANY OF THE FOLLOWING?
AAC understands that there are times when you must miss an appointment due to emergencies or obligations for AAC understands that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another client from getting their much needed treatment. Conversely, the situation may arise where another client fails to cancel and we are unable to schedule you a visit, due to a seemly “full” appointment book! If an appointment is not cancelled at least 24 hours in advance you will be charged a $25 fee.
LATE CANCELLATIONS A late cancellation is considered when a client fails to cancel their scheduled appointment with a 24 hour advance notice.
NO SHOW POLICY A “no-show” is someone who misses an appointment without cancelling it with a 24 hour advance notice. A failure to be present at the time of a scheduled appointment will be recorded in your permanent profile record as a “no-show.”
CREDIT CARD ON FILE POLICY At AAC, we require keeping your credit card or debit card on file as a convenient method of payment for no show fee.
Your credit card information is kept confidential and secure and the $25 cancellation fee will only be processed if AAC is not given the 24 hour notice as stated above. AAC will call to let you know of your missed appointment and that 24 hours after the missed appointment AAC will process the credit card authorized on file to be charged. If you have any questions or dispute please call within the 24 hours of missed appointment.
I authorize AAC (Anti Aging Centers of Connecticut, LLC) to charge $25 for a no show of my scheduled appointment 24 hours after the appointment to my credit card or debit card on file.
I, the undersigned, authorize and request AAC to charge my credit card on file $25 for a no show fee and agree this is my financial responsibility. This responsibility only relates to a missed appointment (no show fee).
I First and Last Name* authorize Anti-Aging Centers of Connecticut LLC and its designated staff to perform Laser Hair Removal on my body. I understand that Laser Hair Removal is an FDA-approved treatment method for removing unwanted hair. I have been advised of the possible adverse reactions as well as the Pre-, Intra- and Post-treatment care which are as follows:PAINThe Laser causes mild discomfort which can be minimized by applying an anesthetic cream approximately 45 minutes prior to each treatment. The DCD or cooling device will be used with the Laser to minimize epidermal damage & pain.CRUSTINGIf superficial crusts form, they should resolve with the gentle care we describe in the aftercare instructions and the office.PIGMENT CHANGESTemporary color changes such as hyper pigmentation, which is a brown discoloration, or hypo pigmentation, which is a skin lightening, may occur. While these can take 3 to 6 months to resolve, they rarely lead to permanent scarring (less than 1% Avoiding sun exposure/tanning beds/self tanners/spray tans before and after reduces the risk of color change. The use of an SPF 46 or higher on the areas of the face/body receiving Laser treatment is highly recommended.PERSISTANCE OF HAIREvaluation of Laser Hair Removal is on going, but studies and clinical experiences suggest that multiple treatments produce long-term hair loss approximately 75-85%. Although some clients respond better than others, most clients will experience progressive hair loss with each treatment. Women’s faces and other male patterned areas on women and men’s backs are areas that are notoriously persistent and may require more maintenance than the average 9-12 treatments due to hormones, age and ethnic backgrounds.EXPECTATIONS755 nm and 1064 nm Lasers are NOT effective on blonde, red, white or grey hairs. Lasers are NOT as effective on fine hairs. A rare, but potential side effect of lasering fine hairs is stimulation of new follicles. Periodic maintenance may be required to maintain results.PRE-TREATMENT INSTRUCTIONS
I acknowledge that I have read the adverse reactions above, and I feel that I have been adequately informed of the risks of Laser Hair Removal treatments. Before each treatment I will inform the Laser Technician if I have taken any new medications since my last treatment or if I have tanned the areas to be treated either by sunlight or artificially. I understand that recently tanned skin should only be treated with the YAG Laser (for dark brown to black hair only) and only after being out of the sunlight, tanning beds, and/or the use of tanning creams for a minimum of 7 days. I also understand that some medications can make my skin photosensitive and either of the aforementioned conditions could cause the Laser to damage my skin. I consent to the taking of photographs during the course of my therapy for the purpose of medical education. I understand that my identity will not be revealed on the photographs or corresponding text. I also agree to comply with the recommended aftercare guidelines which are crucial for healing, prevention of scarring and hyperpigmentation. I agree to cooperate with the recommendations of Anti-Aging Centers of Connecticut, LLC, and I realize that any lack of cooperation could result in less than optimal results.
I certify that I have read and fully understood this form and consent to the procedures referred to in this document. I have had the opportunity to ask Anti-Aging Centers of Connecticut, LLC any questions regarding the proposed treatment. I also certify that I read and write English. By signing below, I acknowledge that I have read and understood all of the information presented to me before signing this consent form. I hereby release Anti-Aging Centers of Connecticut, LLC, its medical staff and technicians from any liability arising out of the services associated with the above treatment.
I have received a copy of the Consent & Client Instructions.