PRIVACY POLICY

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

Chief Medical Officer:  Nada Kader, RN, BSN.  310-401-9001

Purpose: The following privacy policy is to ensure that Jonathan Serebrin MD dba LaserLounge (LL)  complies with requirements of the Health Insurance Portability & Accountability Act of 1996 (HIPPA) as well as California privacy protection laws and regulations. Protection of patient privacy is of paramount importance to LL. Violations of any of these provisions knowingly or unknowingly will result in disciplinary action including termination of employment and possible referral for criminal prosecution.

Notice of Privacy Practices
This Notice of Privacy Policy will be provided to patients at their first encounter and all uses and disclosures of protected health information (PHI) will be accord with LL notice of privacy practices. LL will have copies of the most current Notice of Privacy Policy available for review posted on our web site www.MyLaserLounge.com

Assigning Privacy and Security Responsibilities
Specific individuals at LL are assigned the responsibility of implementing and maintaining the HIPAA Privacy and Security Rules’ requirements.

Deceased Individuals
LL privacy protections extend to information concerning deceased individuals.

Minimum Necessary Use and Disclosure of Protected Health Information
LL will ensure that for all routine and recurring uses and disclosures of PHI (except for uses or disclosures made for treatment purposes; to or as authorized by the patient; or as required by law for HIPAA compliance) such uses and disclosures of PHI must be limited to the minimum amount of information needed to accomplish the purpose of disclosure.

Safeguards
Appropriate safeguards will be in place at LL to reasonably protect health information from any intentional or unintentional use or disclosure that is in violation of the HIPAA Privacy Rule. These safeguards include physical protection of premises and PHI, technical protection of PHI maintained electronically and administrative protection of PHI. These safeguards will extend to the oral communication of PHI and to PHI removed from LL.

Business Associates
LL will ensure business associates comply with the HIPAA Privacy Rules to the same extent as LL, and that they be contractually bound to protect health information to the same degree as set forth in this policy. Business associates permitted to receive PHI include, for example LL billing service, patients’ health insurers, and other healthcare providers with whom we consult and coordinate patients’ care or to whom we refer patients for specialized care. 

LL will ensure that all employees are trained on the policies and procedures governing protected health information and how LLcomplies with the HIPAA Privacy.  New employees will receive training within a reasonable time of employment. 

Sanctions
LL will ensure that sanctions will be in effect for any member of the workforce who intentionally or unintentionally violates any of these policies or any procedures related to the fulfillment of these policies. Such sanctions will be recorded in the individual’s personnel file.

Retention of Records
LL will adhere to the HIPAA Privacy records retention requirement of six years. All records designated by HIPAA in this retention requirement will be maintained in a manner that allows for access within a reasonable period of time. This records retention time requirement may be extended at LL’s discretion to meet with other governmental regulations or those requirements imposed by our professional liability carrier.

Complaints
LL will investigate and resolve all complaints relating to the protection of health in a timely fashion. All complaints will be directed to Practice Manager, who is duly authorized to investigate complaints and implement resolutions.

Prohibited Activities-No Retaliation or Intimidation
No employee or contractor of LL may engage in any intimidating or retaliatory acts against persons who file complaints or otherwise exercise their rights under HIPAA regulations. No employee or contractor may condition treatment or payment on the provision of an authorization to disclose protected health information.

Cooperation with Privacy Oversight Authorities
LL will ensure that oversight agencies such as the Office for Civil Rights of the Department of Health and Human Services will receive cooperation in any investigation relative to protection of health information within LL.   All personnel will cooperate fully with all privacy reviews and investigations.

Investigation and Enforcement
In addition to cooperation with Privacy Oversight Authorities, LL will follow procedures to ensure that investigations are supported internally and staff of LL will not be retaliated against for cooperation with any authority. It is our policy to attempt to resolve all investigations and avoid any penalty phase if at all possible.

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REFUND POLICY

Your happiness matters to us, so before you ask for a refund, please contact our Manager to help process your return request faster or hopefully turn your experience around to a more positive one. 

Manager: Patty Rappa. CCC. Manager.

(310) 401-9001 E-mail: mylaserlounge@gmail.com

 

If you are not happy with your product purchase we are happy to offer a full refund or exchange within 15 days of purchase, minus any shipping costs. 

 

All services purchased on promo or discount rates are final.  They may be exchanged for other spa or medical services of equal or lesser value. Exchanges on packages of treatments will be prorated back to a-la-carte rates and balances will be credited to your account accordingly.   Groupon or other services purchased through third party vendors are non-refundable if they have been started and vouchers have been redeemed.  Voucher specific services must be followed in accordance to the details of the voucher or simply not used at all.  Unused vouchers are refundable via the third party it was purchased through.  Any un-used service or service package purchased at full retail rate or menu rate is 100% refundable within 30-days of purchase.  

 

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Lüz by LaserLounge
1229 Montana Ave STE A
Santa Monica, CA 90403
310.401.9001
 

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Review Lüz by LaserLounge Privacy Policy

 

 

Informed Consent for Laser Tattoo Removal 

As a patient you have the right to be informed about your treatment so that you may make the decision whether to proceed for laser tattoo removal or decline after knowing the risks involved. This disclosure is to help to inform you prior to your consent for treatment about the risks, side effects and possible complications related to laser tattoo removal: 

 

1. The possible risks of the procedure include but are not limited to pain, purpura, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, infection, and unforeseen complications which can last from weeks, months, years or permanently. 


2. I understand that with all laser procedures there is a risk of scarring and Laser tattoo removal is no different. 


3. Short term effects may include reddening, mild burning, temporary bruising or blistering. A brownish/red darkening of the skin (known as hyperpigmention) or lightening of the skin (known as hypopigmentation) may occur. This usually resolves in weeks, but it can take several months to heal. Permanent color change is rare but a possibility depending on the type of ink used during placement. Loss of freckles or pigmented lesions can occur. 


4. Textual and/or color changes in the skin can occur and can be permanent. Many of the cosmetic tattoos and body tattoos are made with iron oxide pigments. Iron oxide can turn red-brown or black. Titanium oxide and other pigments may also turn black. This black or dark color may be un-removable. Because of the immediate whitening of the exposed treated area by the laser, there can be a temporary obscuring of ink, which can make it difficult or impossible to notice a specific color change from the tattoo removal process. 


 

5. Infection:  Although infection following treatment is unusual, bacterial, fungal and viral infections can occur whether or not post care instructyions are followed. Herpes simplex viral infections around the mouth can occur following treatment on the face. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.


 

6. Bleeding: Pinpoint bleeding can occur following treatment procedures. Should bleeding occur, additional treatment/post care may be necessary. 


 

7. Allergic Reactions:  There have been reports of hypersensitivity to the various tattoo pigments during the tattoo removal process especially if the tattoo pigment contained Mercury, cobalt or chromium. Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive treatment. Noted in some patients are superficial erosions, bruising, blistering, milia, redness and swelling which can last up to many months, years or permanently. It is not recommended to have laser tattoo removal treatments if you experienced an allergic reation at/following placement of tattoo. 


8. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, hyper-pigmentation and inorder to achieve optimal desired results. Hot tubs, saunas, swimming pools and excessive sweating/exercise should be avoided until skin is intact. Aftercare guidelines include cleaning the area twice a day and covering with an antibacterial ointment until skin is fully healed and avoiding sun exposure for 2 months after the procedure. If it is necessary to be in the sun, a medical grade sunscreen with SPF 40 or greater must be used and reapplied every 2 hours.  


9. I understand that at minimum, 8-10 treatments will be necessary to achieve desired results. No guarantee, warranty or assurance has been made to me as to the results that may be obtained. Complete tattoo removal is not always possible as tattoos were meant to be permanent and results vary depending on many factors including how long you've had the tattoo, type of ink used and if it was placed by a professional or amateur.


 

 

10.  I understand that the following conditions/situations are contraindications (should not be treated) for tattoo removal. 

Infected skin disorder; open cuts, wounds, abrasions in treatment area.  

Cardiovascular disease ( consent from attending physician required)  

Pacemaker is a direct contra-indication  

Highly anxious patient  

History of epilepsy or seizure disorder – electrical currents may precipitate an attack  

Pregnancy – electrical currents might precipitate labor  

Sunburned or irritated skin in treatment are 

Numb areas without sensation 

Diabetes or other consitions that may impact healing (consent from attending physician required)

Porphyria  


 

 

LIABILTY RELEASE:  I understand  that  results  will  vary  between  individuals.  I understand  that  although  I  may  see  a  change  after  my  first  treatment,  I  may  require  a  series  of  sessions  to  obtain  my  desired  outcome. The procedure  and  side  effects  have  been  explained  to  me  including  alternative  methods;  as  have  the  advantages  and  disadvantages.  I am advised  that  though  good  results  are  expected,  the  possibility  and  nature  of  complications  cannot  be  accurately  anticipated  and  that,  therefore,  there  can  be  no  guarantee  as  expressed  or  implied  either  as  to  the  success  or  other  result  of  the  treatment.  I  am  aware  that  this  treatment  is  not  permanent  as  natural degradation  will  occur  over  time.  I certify that the information I have given is accurate and complete to the best of my knowledge. I hereby release Dr. Serebrin, his medical staff of Registered Nurses, partners and/or associates from any legal or financial responsibility. I  state  that  I  have  read  ( or  it  has  been  read  to  me)  and  understand  this  consent  and  I  understand  the  information  contained  in  it. 

 

I  have  had  the  opportunity  to  ask  any  questions  about  the  treatment  including  risks  or  alternatives  and  acknowledge  that  all  my  questions  about  the  procedure  have  been  answered  in  a  satisfactory  manner.   

April 24, 2024 

 

I authorize Luz Aesthetics to take photos and/or video for sole purpose of education with marketing materials on our website, social media.  All photos and videos are kept in patients file with a  HIPPA compliant database only accessible to Luz Aesthetics staff. I understand I not be reimbursed for usage. I understand and agree that these materials shall become the property of Luz Aesthetics’s and will not be returned.


April 24, 2024

 

I understand I’m getting consulted and treated by Dr. Edmund Fisher’s Nurse Practitioners and Registered Nurses today


April 24, 2024

 

 

 

CALIFORNIA MEDICAL SERVICES CONTRACT  

All Medical treatments are performed by Jonathan Serebrin MD, Inc. Medical Group, at LaserLounge 

A signed copy of this document is to be emailed/given to the client upon request. Original is to be filed in Client’s medical records. Arbitration Agreement California CD0501Y8v2 

ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforceability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages.  Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.  Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph.  Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive law of California. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction in California. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place in California. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court of California or a federal district court in California. Discovery shall proceed in accordance with California Code of Civil Procedure, §§ 1283.1, 1282.05, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence. Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division.  Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions.  NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP  YOUR RIGHT TO JURY OR COURT TRIAL. 

I have read and agree to the terms/conditions listed in this agreement and understand that I have the right to receive a copy of this arbitration agreement upon request.

 April 24, 2024

 

 

 

Please select who is receiving the consult/treatment today
AdultMinor
Continue
First Client's Name

First Name*

Middle Name

Last Name*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

Social Security Number *
First Client's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Tell us about the tattoo....
Have you ever had laser tattoo removal before? (this tattoo or others?)*
No
Yes, but to a different tattoo.
Yes, I've had laser tattoo removal treatments to this tattoo.

When did you get the tattoo? (exact date not required, an estimate will suffice) *

Where is the tattoo located on your body? *
Who placed the tattoo?*
What colors were used? (select all that apply) *
Black Ink
Blue Ink
Grayscale Ink
Green Ink
Light/Sky Blue
Orange Ink
Pink Ink
Purple Ink
Red Ink
White Ink
Yellow ink
To your knowledge, were multiple colors mixed to make the tattoo ink?
Yes
No
Unsure

Why do you want to remove the tattoo?
Was this tattoo placed to cover up a previous tattoo?*
No
Yes
Do you desire complete or partial removal?*
Complete
Partial/Faded (usually to be covered by a new tattoo)
Did you experience an allergic reaction to the ink after getting the tattoo?*
No
Yes
Is the tattoo raised?*
No
Yes
Do you have a history of Keloid/raised scarring?*
No
Yes

Any medical conditions that you see a physician regularly for? Leave blank if none *

Please list all medications and/or vitamins currently taking. If none, leave blank.

Any allergies to any medications or ingredients in products? If none, leave blank.
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Social Security Number *
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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