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Laser Hair Removal Informed Consent Form

I hereby authorize and direct any associates or assistants of Pure Cosmetics, PLLC. to perform laser assisted hair removal on me. I understand that this procedure works on the growing hairs and not the dormant hairs. For this reason, complete destruction of all hair follicles from any one treatment is unlikely, and I understand that I will require several treatments to obtain significant, long-term reduction of hair growth. I also understand some people may not experience complete hair loss even with multiple laser procedures.

The following points have been discussed with me:

  • The potential benefits of the proposed procedure.
  • The possible alternative procedures.
  • The probability of success.
  • The reasonably anticipated consequences if the procedure is not performed.
  • The most likely possible complications/risks involved with the proposed procedure and subsequent healing period, including, but not limited to: infection, scarring, regrowth of hair, and/or blistering.

Post treatment instrutions:
I am aware of the following possible experiences/risks with laser hair removal:

  • DISCOMFORT: some discomfort may be experienced during laser treatment.
  • WOUND HEALING: laser hair removal can result in swelling, blistering, crusting or flaking of the treated areas, which may require one to three weeks to heal. Once the surface is healed, it may be pink or sensitive to the sun for an additional 2-4 weeks, or longer for some patients.
  • BRUISING/SWELLING/INFECTION: With some lasers, 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 formed.
  • PIGMENT CHANGES: During the healing process, there is a slight possibility that the treated area can become either light or darker in color compared to the surrounding skin. This is usually temporary, but on rare occasion, may become permanent.
  • SCARRING: Scarring is a rare occurrence, but it is a possibility when the skin’s surface is disrupted. To minimized the chance of scarring, it is IMPORTANT that you follow all pre- and post-treatment instructions carefully.
  • EYE EXPOSURE: Protective eyewear will be provided. It is important to keep these on at all times during the treatment in order to protect your eyes from laser exposure.

By signing below, I certify that I have read and fully understand the contents of this consent form for laser hair removal treatment with Pure Cosmetics, PLLC., and that all disclosures referred to herein were made me to me.

First Patient's Name

First Name*

Last Name*
First Patient's Date of Birth*
First Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Third Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Fourth Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fifth Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Sixth Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Seventh Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Eighth Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Ninth Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Tenth Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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