Laser Hair Removal Informed Consent 2020

1. Informed Consent. The purpose of this Informed Consent is to help you decide whether a laser hair removal ("LHR") cosmetic procedure is right for you and to help you make an informed decision to undergo this procedure. This Informed Consent gives you general information about LHR cosmetic procedures, explains other treatment options, and identifies the benefits, risks, side effects and possible complications associated with LHR procedure

2. Laser Hair Removal Procedure. LHR is a non-invasive laser treatment designed to remove unwanted hair from all parts of the body. The laser device works by emitting pulses of light energy that penetrate the skin and destroy hair follicles while a separate device, called a Zimmer, cools the surrounding skin. Because the laser light needs to fill or "see" the hair follicle to work effectively, it is important not to wax, tweeze, have electrolysis procedures or pluck the hair for 2-4 weeks prior to the procedure. You will be required to wear protective eyeglasses during the procedure to protect your eyes from the laser light. You may feel a slight burning, stinging or pinching sensation during the procedure, It generally takes 10 to 21 days after the procedure for the treated hair to fall out. Treatment of dark coarse hair generally achieves the best results while removal of light fine hair generally requires additional treatments that may or may not be successful. Clinical results of LHR may also vary depending on individual skin type, hormonal levels, and hereditary influences. Therefore, some patients may experience partial results and some may notice no improvement at all. Future hormonal changes may cause additional hair growth. LHR procedure generally involves a series of treatments. Ideal (light skin/dark hair) candidates can usually achieve a 65%-90% reduction with a series of 6 treatments. Thicker skinned areas such as men's backs, faces or neck usually require more than 6 sessions and occasionally achieve only partial reduction or hair thinning.

3. Alternative Procedures. LHR is a voluntary cosmetic procedure that is not necessary or required

4. Not Good Candidates. Generally, you are not a good candidate for the LHR procedure if you are pregnant, nursing or plan to become pregnant while undergoing LHR treatments. Individuals who have used Accutane within the past six months or who used any medications requiring limited exposure to sunlight are not good candidates for the LHR procedure. Individuals with recently tanned skin are advised to delay undergoing the LHR procedure. The laser may not be effective on blond or gray hair. Sun exposure 2-4 weeks prior to treatment may reduce the effectiveness of the laser. It is important to shave the area prior to the treatment session. ( we do not provide shaving services as you must do this yourself prior to the treatment Please inform us if you have an allergy to Aloe

5. Risks and Complications. All medical and cosmetic procedures are associated with certain risks and may result in complications. Possible risks and complications associated with LHR procedure include:

Temporary reddening, burning, swelling, bruising or discoloration of the skin over the treated area

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Blistering, scarring, activation of cold sores, infection or permanent discoloration, which may occur in rare cases. Please inform us if you have ever had a problem with cold sores

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Folliculitis, which is an infection of the hair follicle, which may take several days to resolve

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Hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin), which rare may take several months to fully resolve

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Crusting or blistering of the area exposed to the laser, which is rare and which may take several days to heal

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As with all LHR procedures, some re-growth of hair may occur after treatment sessions arecompleted.

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6. Post Procedure Instructions. It is important that you comply with all post-procedure instructions In addition, it is important that you limit sun exposure after the LHR procedure and use protective sunscreen lotion Please call your doctor promptly if complications develop after the procedure. Laser-treated areas should not be exposed to sun or tanning beds. Not adhering to the post-treatment skincare instructions may increase the risk of complications. By signing this Informed Consent, you understand and agree as follows.

The information contained in this Informed Consent was explained to me using terms I could understand, and all my questions and concerns have been answered After reviewing all the information provided to me about cosmetic procedures and reviewing my health status, I believe I am a good candidate for the LHR procedure Initial

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I understand that LHR is an elective procedure and hereby freely accept all possible risks,complications and side effects that may result from this procedure.

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I acknowledge that the LHR procedure will be performed by a licensed Medical Provider of New Skin and Body Aesthetics, who is properly trained and certified in its usage.

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I agree to return for any recommended follow up visits and follow all post-procedure instructions

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I understand that no guarantees have been made to me regarding the outcome of the LHR procedure.

This consent form is valid for all future laser hair removal treatments performed, and I will alert thestaff if there are any future changes to my medical history, or if I become pregnant.

Tanning the last 2 weeks.

YESNO

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Antibiotics

YESNO

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Accutane

YESNO

Initial

HIV

YESNO

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Active herpes simplex virus

YESNO

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Patient's First Name

Patient's Last Name

Email

example@example.com

Patient's Signature

Date

Provider Name

First NameLast Name

Provider Signature

Date

Laser Hair Removal Consent

YES or NO and Initial all that apply: