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Laser Informed & Consent Form

Let us do this part
Today's Date:
Sun May 18 2025 09:38
Please read and answer
 
Area to be treated:**
 
Y
N
Illnesses/Medical conditions*
Details:
 
Y
N
Allergies:*
Details:
 
Y
N
Present medications:*
Accutane, Antibiotics, Aspirin, Antiviral, Iron supplements, Gold therapy, Coumadin, drugs which may cause
photosensitivity this includes herbal supplements (list medication and dosages):
Details:
 
Y
N
Past medications*
Please list dosage of oral antibiotics or Accutane and date of last dose taken:
Details:
 
Y
N
Do you have a history of any autoimmune disease?*
Y
N
Do you have a history of HSV 1 or HSV 2?*
Y
N
Do you have any implants/injectables/permanent makeup?*
If so, please list:
Details:
 
Y
N
Do you have any tattoos?*
If so, please list locations:
Details:
 
Y
N
Are you pregnant?*
Y
N
History of keloids/hypertrophic scares:*
Details:
 
Y
N
Tanning history*
Please list and include last date of use (includes direct sun, self tanners, spray tans):
Details:
 
Y
N
Have you previously received laser treatment?*
Specify date/number of treatments:
Details:
 
Y
N
Previous hair removal history:*
Include frequency and last use of modalities (Wax Epilator, Plucking, Electrolysis, Bleaching, Shaving, Waxing):
Details:
 
Y
N
Have you ever had cosmetic peel/procedure?*
Please list:
Details:
 
I authorize to perform lase treatments with Laser GentleMaxPro too treat my condition (laser hair removal, pigmentation, veins removal, wrinkle reduction).

Representative staff including the operator/technician who will be performing the procedure and others who represent
the organization and may have been engaged in the consultation describing the procedure (hereinafter the "staff") have
answered all of my outstanding questions about the procedure.
The Laser is a device that produces an intense but gentle burst of light. This light is absorbed by and causes selective
heating of certain cells in your unwanted lesion. Lesions most commonly fade slowly over time as these destroyed
cells are eliminated by normal body processes. My eyes will be covered with laser -specific safety eyewear or an
opaque material to protect them from the intense light.
My eyes will be closed and I will not attempt to remove the eye protection during treatment.
I have been informed of the following possible risks and complications of this procedure including but not limited to:
(Circle all that apply) Purpura (red-purple discoloration, bruising, itching (hive-like response which lasts 2-3 hours to
2-3 days) Herpes simplex virus activation, Burns, blisters, scabbing, crusting, skin colour and /or textural changes
Hyperpigmentation (darkening of the skin; transient or long term) Hypopigmentation (lightening of the skin; transient,
long term or possibly permanent) Scarring (rare; possibly permanent)
I understand that complete clearing may not be possible and will depend upon the type, age and colour of the lesion.
Multiple treatments may be needed for the best results.
Other methods of treating this condition have been discussed with me such that I may assess the risks and benefits of
these alternative treatment methods.
Anesthesia is usually not necessary. My provider or I may elect to use a form of topical anesthesia to reduce any
discomfort during the procedure. A cryogen spray skin-cooling device may be used during the procedure to decrease
discomfort and protect the skin. All anesthesia options and risks will be discussed with me in advance.
I understand that immediately following the laser treatment redness; swelling, discomfort, bruising and discoloration
may develop at the treatment site. I understand discoloration may last 7-14 days and swelling should resolve within
several days. Discomfort may be treated with the application of cool compresses or topical soothing agents.
None of the staff have made any promises or warranties or guarantees as to the success or effectiveness of the
procedure. The goal of the procedure and the outcome can be influenced by many factors. I understand that 15% if the
population does not respond to laser treatments. I also understand that there may be a requirement for more treatments
than originally anticipated.
I will be given complete instruction regarding after care of the treated area. It is important to follow after care
instructions to help minimize the chance of complete healing, skin textural changes or scarring. Sun avoidance and use
of sunscreen may be recommended. Tanning should be avoided.
Contraindications to the performance of this procedure have been discussed in detail with me.
I have been given the opportunity to ask questions about the procedure.
My questions have been answered and I understand the information given to me.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:*
Address:*
Postcode:*
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:*
Email:*
Signature:*