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Laser Hair Removal at LüzLounge Informed Consent

I duly authorize and consent to the registered nurse with the Edmund Fisher M.D. at LüzLounge  to perform Laser Hair Removal and any other measures which in their opinion may be necessary. 

I understand that clinical results may vary in different skin types and hair types and that my pre/post care instructions must be adhered to in order to achieve optimal results. I understand there is a possibility of short-term effects such as reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me.

Clinical results may vary depending on individual factors, including medical history, skin and hair type, patient compliance with pre/post treatment instructions, and individual response to treatment. I understand that laser hair removal is a safe alternative to methods used for removing unwanted hair, such as shaving, waxing, chemical epilation and electrolysis. I understand that laser hair removal involves a series of treatments and may require additional sessions and/or touch ups and that the fee structure has been fully explained to me.

I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. 

I confirm that I am not pregnant at this time and will inform Lüz Lounge staff if I become pregnant. 

I confirm that I have not taken Accutane within the last 6 months and will inform my nurse if I am prescribed Accutane during my treatment series and discontinue my sessions immediately. 

I confirm that I have not and will not use any topical retinoids or acid based skincare (Kojic, Azelaic, Tranexamic, Salicylic, Glycolic, Ascorbic) on the desired treatment area for 2 weeks before my laser treatment and that LüzLounge and its medical staff are not responsible for any complications or additional treatments that arise from doing so. 

April 21, 2024

I consent to the taking of photographs/videos and authorize their use for the purposes of medical audit, education and promotion. ( If you do not consent, put an "X" in as your inital)

April 21, 2024

I understand that there is a $10 shaving charge if I have come to my appointment unshaved.( Please let us know if you need assistance shaving so we can allow enough time for your treatment)

April 21, 2024

 

Nurse requests for Laser Hair Removal

Everyone always has a favorite and we do our best to schedule you with yours but you may not always get the same person.  We are not able to make any guarantees due to illness, vacations, and unforeseen schedule changes. We will try our best to fulfill nurse requests. The good news is all our medical staff and aesthetics team are all trained and certified. They also make excellent notes in your chart, so no matter who does your treatment it will be great! In regards to more specialized services such as skin repair, tattoo removal, injectables such as Dysport and Filler, we know trust and relationship are important. We have a bit more flexibility there, so we will always do our best to fulfill your request for your favorite team member.  If you still desire your preferred practitioner, you may reschedule but within the 24 hour cancellation policy. No one will judge you, we promise.

April 21, 2024

IMPORTANT: I acknowledge the following cancellation policy:

If I do not cancel my appointment within 24 hours of my appointment time, I am subject to a $25 fee for treatments under 30 minutes,  $50 for treatments over 30 minutes, $100 for treatments over 60 minutes (including FULL BODY LASER) or prepaid sessions deducted from my account.

April 21, 2024

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

April 21, 2024

I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form. 

April 21, 2024

 

STATE  MEDICAL SERVICES CONTRACT  All Medical treatments are performed by Edmund Fisher MD and Noam Rosines MD Inc. Medical Group, dba Luz Lounge. 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 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 State law, and not by a lawsuit or resort to court process except as State 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 enforce ability 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. 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. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place. 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 or a federal district court. Discovery shall proceed in accordance with State 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 agreement upon request.

 April 21, 2024


 


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

First 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

Please list any and all current medical conditions. If none, leave blank.

Please list all medications you are taking, including supplements and multivitamins. If none, leave blank.

Please list any allergies. If none, leave blank.
Have you ever had Laser Hair Removal in the past?*
No
Yes
Are you currently on any antibiotics?*
No
Yes
Have you been prescribed Accutane within the last year?*
No
Yes
Any history of keloid scaring?*
No
Yes
Any history of cold sores?*
No
Yes
Any history of genital herpes?*
No
Yes
Is the desired treatment area currently tanned?*
No
Yes
Do you use sunscreen regularly?*
No
Yes
Within the last 10 days, have you used any vitamin A derivatives on the desired treatment area? (ex Retin-A or retinol)*
No
Yes
First Client's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
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*

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

Please list any and all current medical conditions. If none, leave blank.

Please list all medications you are taking, including supplements and multivitamins. If none, leave blank.

Please list any allergies. If none, leave blank.
Have you ever had Laser Hair Removal in the past?*
No
Yes
Are you currently on any antibiotics?*
No
Yes
Have you been prescribed Accutane within the last year?*
No
Yes
Any history of keloid scaring?*
No
Yes
Any history of cold sores?*
No
Yes
Any history of genital herpes?*
No
Yes
Is the desired treatment area currently tanned?*
No
Yes
Do you use sunscreen regularly?*
No
Yes
Within the last 10 days, have you used any vitamin A derivatives on the desired treatment area? (ex Retin-A or retinol)*
No
Yes
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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