Laser Hair Removal – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical supervision or taking medications? *

Yes

No

If yes, please provide details:

Are you currently taking any medications? ( List names of the ones who apply):

Antibiotics
Hormones
Accutane
Retinoids
Blood thinners
Steroids

Have you had recent cosmetic treatments in the area targeted? *

Yes

No

Have you had laser hair removal before? *

Yes

No

If yes, please let us know details:

Do you have any tattoos or permanent makeup near the area to be treated? *

Yes

No

Do you have any tattoos or permanent makeup near the area to be treated?

Let us know :

Skin Type (Fitzpatrick I-VI):

Recent sun exposure/tanning in the last 4 weeks? *

Yes

No

If yes, date of last exposure

Risks, Side Effects, and Acknowledgements

Please read and initial each statement regarding the Laser Hair Removal: *

I understand laser targets hair follicles and results vary.

I acknowledge multiple treatments are required.

I understand side effects can include redness, pigmentation change, etc.

I will notify the clinic of any adverse reactions.

I agree to pre/post care instructions.

I confirm no Accutane use in last 6 months.

I consent to before/after photos for documentation.

Client Declaration and Consent

I confirm I have read and understood the information provided.

I have had the opportunity to ask questions.

All questions were answered to my satisfaction.

I consent to laser hair removal at Idens Laser Clinic.
I understand that I need to let the clininc know 24 hours prior to an appointment, rescheduling or cancelling my appointment

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

I agree to terms & conditions provided by the company.

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Laser Hair Removal – Comprehensive Consent and Concern Form

Do you have any tattoos or permanent makeup near the area to be treated?

Risks, Side Effects, and Acknowledgements

Client Declaration and Consent

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