2021 Laser Hair Removal & Skin Rejuvenation Intake Forms

CANCELLATION/NO SHOW POLICY
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).
Cardholder Name: *
Cardholder Signature: *

Parent/guardian signature required if client is under 18. Clear

Consent Form & Pre/Post Treatment Instructions
Laser Hair Removal Consent & Pre/Post Instructions

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:

PAIN
The 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.

CRUSTING
If superficial crusts form, they should resolve with the gentle care we describe in the aftercare instructions and the office.

PIGMENT CHANGES
Temporary 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 HAIR
Evaluation 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.

EXPECTATIONS
755 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
1. Avoid the sun:
2. - 7-14 days before and after YAG treatments (tan skin & dark skin) with dark brown to black hair only
3. - 4-6 weeks before and 1 week after GentleLASE Alexandrite treatment (light skin with no tan)
4. You MUST avoid bleaching/NAIR and self tanners for 1 week, and avoid plucking or waxing hair for 2-4 weeks prior to treatment.
5. If you have a history of perioral herpes, prophylatic antiviral therapy may be started the day before treatment and continued 1 week after.
6. Avoid antibiotics prior to treatment for 1-2 weeks to avoid photosensitivity. For clients treating their face, please discontinue Retin A for at least 1 week, no Accutane in prior 6 months, no injectable filler for 4 weeks prior to treatment, and no Botox 1 week before and 1 week after.
7. The laser seeks melanin and is attracted to dark colors. Please wear white or light colored undergarments if you are treating your bikini area.
8. Tanned skin can be treated with the GentleYAG laser but avoiding direct exposure to the sun or tanning beds in the treatment area is always recommended for at least one week before and after treatments. Please call the office and make the staff aware if there is any color change to skin in the treated area before treatment.
9. Skin should be free of all products: makeup, deodorant, creams, oils, etc.
INTRA-TREATMENT CARE
1. The skin is cleaned and shaved or left with one day of new growth.
2. Safety considerations are important during the laser procedure. Protective eye wear will be worn by the client and all personnel during the procedure.
Page 1 of 2 Client Signature: *

Parent/Guardian signature required if client is under 18. Clear

Laser Hair Removal Consent & Pre/Post Instructions Continued
1. Immediately after treatment, there should be erythema (redness) and edema (swelling), bumps at the treatment site which may last from 15 minutes to 24 hours. The erythema may last up to 2-3 days. The application of ice during the first few hours after treatment will reduce the discomfort and swelling that may be experienced but we recommend only aloe vera gel or Elta Md enzyme gel after treatment. Rarely, minor epidermal blistering may occur in which case poly-sporian cream may be applied. If this should happen, please contact our office immediately and a nurse will give you further instructions.
2. Makeup may be used immediately after treatment unless there is epidermal blistering. It is recommended to use ONLY NEW makeup to reduce the possibiities of infection (Folliculitis).
3. Avoid sun exposure to reduce the change of hyperpigmentation or darker pigmentation for 7 days post treatment. Use SPF 46 or greater at all time throughout the course of the treatment.
4. Avoid picking or scratching of the treated skin. If you are experiencing itchy skin, apply 1% hydrocortisone cream or Elta Md enzyme gel as needed to avoid irritation. Do not use any other hair removal treatment products or similar treatments (waxing, electrolysis or tweezing) that will disturb the hair follicle on the treatment area for a minimum of 2 weeks after the treatment is performed. Shaving may be performed.
5. Call our office with any questions or concerns you may have after the treatment. Return to our office or call for an appointment at the first sign of the return of hair growth. This can mean 4-6 weeks for the upper body treated and possibly as long as 6-12 weeks for the lower body. Hair regrowth occurs at different rates on different areas of the body. New hair growth will not occur for at least three weeks after treatment.
6. Anywhere from 5-21 days after the treatment, shedding of the surface hair may occur and this appears as new hair growth. This is not new hair growth. You can clean and remove the hair by washing or wiping the areas with a wet cloth or loofa sponge or shaving 48 hours after the treatment.
7. After the underarms are treated, avoid reapplying deodorant for 30+ minutes to avoid irritation.
8. There are no bathing restrictions except to treat the skin gently. For 48 hours: No scrubbing, rubbing or harsh products; treat as if you have sunburn. We recommend Dermalogica Clearing Wash to cleanser the area for 48 hours. The product clears bacteria and normalizes the pH of the skin.
9. Exercise is not recommended for the first 24 hours after treatment to avoid irritating follicles. 10. Being compliant and keeping scheduled appointments suggested by AAC and your technician is crucial for best results. Non-compliance can add to the number of treatments needed as we may miss growth cycles of the hair follicle. Average number is 9-12 treatments excluding male patterned areas on women.
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.
Page 2 of 2 Client Signature: *

Parent/Guardian signature required if client is under 18. Clear
I have received a copy of the Consent & Client Instructions.
Client Signature: *

Parent/Guardian signature required if client is under 18. Clear
Should be Empty:

CLIENT INTEREST QUESTIONNAIRE

AAC MEDICAL HISTORY FORM

FITZPATRICK SKIN TYPING

CANCELLATION/NO SHOW POLICY

Consent Form & Pre/Post Treatment Instructions

Laser Hair Removal Consent & Pre/Post Instructions