Laser Hair Removal Client Consent and Waiver of Liability FormΔLocation Date First Name Last Name Email I hereby authorize and give my consent to technicians of Zia Cosmetic Clinic to perform laser-assisted hair removal on me. I understand that this procedure works on growing hairs, not dormant ones. For this reason, complete destruction of all hair follicles from any one treatment is unlikely. I understand that multiple treatments are needed at regularly spaced intervals to treat all the hair in a treatment area for significant reduction of hair growth. Six treatments are typical, but some people require more. Hair loss may be permanent after several treatments, but not in all cases. Touch-up treatments may be needed in the future. Results vary with the individual depending on skin color, hair color, and hair density. Recurrence of hair growth may occur at the treated site. I understand results are not guaranteed. Some of the factors that could trigger new hair growth are hormonal imbalance, pregnancy, medications, menopause, tweezing, or waxing. I also understand some people may not experience complete hair loss even with multiple laser procedures. I acknowledge that the following points have been discussed with me: (Client: Please initial next to each section)1.Contraindications I understand that tanning during the course of my laser treatments is not recommended and can cause several complications. I understand that treatment is not recommended for tanned patients until the tan has faded and that sun exposure must be avoided between treatments. I understand that I should avoid direct sun exposure for 6 weeks after my laser treatment, this also includes tanning beds. I have been informed to use a sunblock with an SPF of 30 or higher on the treated area during the course of the laser treatments. I understand that it is my responsibility to inform my laser technician if my skin is any darker than when the treatment first started. Artificial tanning products must be discontinued two weeks prior to treatments. Laser therapy is not recommended if any of the following conditions exist: Pregnant or Nursing Female, Photosensitivity disorder, Immunosuppressive disease, Diabetes, Tanning, Bleeding Disorder, Seizure disorder triggered by light, active Herpes, active Shingles, or any active infection. I have notified my treating technician if I have one or more of the conditions above.2.Treatment Cost I know the cost3.Possible complications/risks involved with the proposed procedure and subsequent healing period. DISCOMFORT - Some discomfort may be experienced during laser treatment. WOUND HEALING - Laser Treatment can result in swelling, blistering, crusting, or flaking of the treated areas, which may require one to three weeks to heal. Once the surface has healed, it may be pink or sensitive to the sun for an additional two to four weeks, or longer in some patients. BRUISING/SWELLING/INFECTION - Bruising of the treated area may occur. Additionally, there may be some swelling noted. Finally, skin infection is a possibility although rare, whenever a skin procedure is performed. PIGMENT CHANGES (Skin Color) - During the healing process, there is a slight possibility that the treated area can become either lighter or darker in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion. it may be permanent. SCARRING - Scarring is a rare occurrence, but it is a possibility when the skin's surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions carefully. EYE EXPOSURE - Protective eyewear (shields) will be provided. It is important to keep these shields on at all times during treatment to protect your eyes from accidental laser exposure.4.Post-Treatment Instructions A printed copy of these instructions has been given to me and I understand them completely. I accept responsibility for complying with the treatment care instructions provided.5 5.consent to have photographs taken during the course of my laser treatments to be retained as part of my file maintained by Zia Cosmetic Clinic. I understand all photographs are the property of Zia Cosmetic Clinic and are kept confidential.6 6.I agree that I have been offered a patch test.Skin Tone Pink Olive Mediterranean Asian Item 2 BlackSkin Type Fine Normal Thick9 9.I have read and understood all information presented to me before signing this consent. I have had ample opportunity to ask questions regarding laser hair reduction, side effects, and aftercare. I also understand it is my responsibility to inform my laser technician of any medical history, tanning, pregnancy, or prescription changes.10 10.I confirm the answers I have given in this form are correct, and I have not withheld any information requested by this form. I have been informed of the proper use of equipment for the services I'm receiving I acknowledge and agree that I'm responsible for my own health, Zia Cosmetic Clinic technicians are not responsible. I have been advised of all risks associated with the services and procedures I will be receiving. I agree to comply with all the instructions directed by the Technician. I hereby release Zia Cosmetic Clinic and its affiliates, officers, directors, agents, employees, and contractors from liability from any injury, loss, claim, or damage that may result from the services provided or treatment rendered, this release binds my heirs, successors, and assigns.EXISTING OR PAST CONDITIONS (Please check all that apply)RESPIRATORY Smoker Shortness of Breath Asthma Emphysemas Chronic Bronchitis Sinusitis Other other HEAD/NECK Headaches Tension Migraines Whiplash Jaw Pain/TMJ Earach Vision Problems Contact Lenses OtherDate other CONTAGIOUS Aids/HIV Hepatitis Immune Disorders Nail Fungus Cold Sores Ringworm Athletes’ Foot (Left or Right) Warts AreaArea FEMALE ( Pregnant First Pregnancy ) Yes NoTrimester 1st 2nd 3rd Complications Menopausal Problems Menstrual Problems BreastfeedingNERVE Sciatica Carpal Tunnel Syndrome Multiple Sclerosis Parkinson’s Disease Seizures (Cause: ) Decreased Sensation OtherSeizures (Cause: ) Other DIGESTION General Difficulties Constipation Diarrhea IBS/IBDSKIN Burns/Wounds Bruise Easily Moles Psoriasis Rosacea Keloids Age Spots Dark Circles around eyes Puffiness around eyes Acne Acne Scarring Cysts Ingrown Hairs Irritation Hairs Sun Damage/Hyper Pigmentation OtherOther CARDIOVASCULAR High Blood Pressure Low Blood Pressure Poor Circulation (Area: ) Heart Disease (Type: ) Stroke (Date: ) Enema/Swelling (Area: ) Phlebitis Varicose Veins (Area: ) Spider Veins (Area: ) Vertigo/Dizziness OtherPoor Circulation (Area:) Heart Disease(TyPe:) Date Enema/swelling (Area;) Varicose Veins (Area;) Spider Veins (Area;) Other OTHER Cancer Arthritis (OA, RA, DDD) Diabetes (I, II) Decreased Sensation Cysts/Tumors History of Blood Clots Bursitis Scoliosis Gout Fibromyalgia Tanningcancer (location,Type,Date) Arthritis (OA, RA, DDD) Location: 1 I declare that all information provided by me in this form is accurate and complete. Any omission, concealment, or incorrect information is solely my responsibility, and I release Zia Cosmetic Clinic and its staff from any liability arising from such inaccuracies.Submit Form
