Laser Hair Removal Consent Form

Please complete form including Medical History

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Are you currently (or possibly may be) pregnant?

Select

Do you have any allergies or intolerances?

Select

Have you taken any anticoagulants (e.g. warfarin) or antiplatelet drugs (e,g, aspirin) within the last 6 months

Select

Are you currently taking any medications?

Select

If Yes, Please specify

Have you been treated/taken medication for cancer within the last 6 months?

Select

If Yes, Please specify

Medication/Treatment

Have you used Roaccutane, Isotretinoin or Retin-A within the last 6 months?

Select

Are you taking any contraceptives?

Select

Have you ever had Botox or Collagen injections?

Select

What areas will be treated?

Please type all the areas you will be having laser hair removal on.

Print and Date:

Please print full name and date

Laser Hair Removal Consent Form

Laser Hair Removal Contraindications

Contraindications to operation:

If there is a history of keloid, allergies or scarring of the physique of the person does not recommend treatment;

suffering from hepatitis, syphilis, skin infection is not recommended for treatment; blood diseases and coagulation mechanism disorders, menstrual period women do not recommend treatment;

preoperative administration of vascular dilatation drugs, anti-joint pain drugs are not recommended for treatment;

The use of 13-shun retinoic acid history within 6 months is not recommended for treatment;

During 6 weeks, treatment was not recommended for those who had used other methods (such as wax removal);

There is a heart disease, the device has the cardiac rhythm regulator and the pregnant woman does not recommend the treatment;

Those who have recently received sun exposure are not recommended for treatment;

Those with open wounds are not recommended for treatment;

Those with infected wounds are not recommended for treatment;

Patients with skin diseases and epilepsy are not recommended for treatment.

Aftercare:

1. After hair removal do not use scrub, alcohol, antiperspirant, bath should use warm water, hair removal area do not use hot water hot wash and hard scrub;

2. Don't do sauna or swim in the swimming pool or beach within one week after hair removal.

3. Do not use cosmetics and skin care products containing fruit acid and A acid after depilation.

4. The depilated area may produce slight redness and swelling, sensitive skin, hot or itchy sensation. Ice compress can alleviate the pain if you feel pain.

5. Avoid sunshine as much as possible and use sunscreen when you go out.

6. Pay attention to the cleanliness and dryness of the depilation area. Do not wear clothes that are not clean or too tight to ensure that they are dry and breathable.

7. Pay attention to diet, prohibit smoking and alcohol, do not eat spicy stimulating foods, to supplement more vitamin C.

Laser Hair Removal Consent Form

Laser Hair Removal Consent Form

Laser Hair Removal Contraindications

Contraindications to operation:

Sherman Oaks, CA

Norco, CA