At AAC our focus is to create a customized client experience in order to help you achieve your skin care and anti-aging goals. This questionnaire helps us decipher your needs and allows us to better guide you on your journey to your best self!
Have you ever had any of the following?
I, full name*, authorize Safelase Institute of Connecticut LLC dba Anti-Aging Centers of Connecticut 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 detailed below.
PAIN The laser causes mild discomfort which can be minimized by applying an anesthetic cream approximately 45 minutes prior to each treatment, to be purchased in advance if needed The DCD, or cooling device, will be used with the laser to minimize epidermal damage & pain.
CRUSTING If superficial crusting occurs, it should resolve with the gentle care we describe in the office, and in the post-treatment instructions.
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 treatment reduces the risk of this occurring. The use of an SPF 46 or higher on the areas receiving laser treatment is highly recommended.
PERSISTENCE OF HAIR Evaluation of laser hair removal is ongoing, but studies and clinical experience suggests that multiple treatments produce long-term hair loss of 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 notoriously persistent and may require more maintenance than the average 9-12 treatments. Factors that may lead to more than the average number of treatments include: hormonal imbalances, age and ethnic background.
EXPECTATIONS 755 nm and 1064 nm lasers are NOT effective on blonde, red, white or gray 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.
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 in 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, 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 staff, 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, its medical staff and technicians from any liability arising out of the services associated with the above treatment.
| have received a copy of the Consent & Client Instructions
We understand emergencies happen, and you may not always be able to call in advance. However, please know that when you "no show' or cancel an appointment within 24 hours, you are preventing other clients from receiving their services. In addition, our technician is left without a client to serve, and when this happens frequently, it hurts our whole AAC family.
If you need to adjust, reschedule or cancel your appointment, please call and leave us a voicemail if you do not speak directly with a staff member. This way, we will be able to continually adjust our schedule to best accommodate our clients, and we will have a record that you called outside of the 24 hour timeframe. We will always get back to you once we receive your message.
In the event that you 'no show' or cancel your appointment within 24 hours, we will charge the credit card on file a 'no show' fee in the amount of $25.00 if the appointment is scheduled for less than 60 minutes. If the appointment is scheduled for 60 minutes or more, you will be charged a $75.00 'no show' fee. If the credit card on file declines, the "no show' fee will be added to your account with us, and you will owe the amount to be paid in full at your next scheduled appointment.
AAC is an in-demand, busy medical spa. Please note that canceling or rescheduling appointments with short notice may result in longer waiting times for appointments, and AAC cannot guarantee you will be able to stay on your recommended treatment plan schedule.
At AAC, we do require that a credit card or debit card is kept on file as a convenient method of payment, in the event of a "no show' or late cancellation (within 24 hours of scheduled appointment time Our credit card information is kept
By signing below, I authorize AAC (Anti-Aging Centers of CT) to charge a no show fee to my credit or debit card on file, in accordance with all of the above information if I "no show' or cancel an appointment within 24 hours. I, the undersigned, recognize that it is my financial responsibility to pay any incurring fees in accordance with this policy.