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Sixth Ave Laser Spa Consent Form

Today's Date: April 18, 2024

PLEASE READ CAREFULLY:

I do understand that laser hair removal is not 100% permanent but a reduction of up to 90%.
Results may vary depending on skin tone, hair color, and any medical/health conditions.
Laser Hair Removal IS NOT EFFECTIVE on BLONDE and GREY hair.

I do understand the cancellation and rescheduling policy and agree to pay the appropriate fees if I do not cancel or reschedule within 24 hours of my appointment date and time.

I do understand that taxes and gratuities are not included in any service I purchase. It is common practice to tip 15-20% of the original service price. Please feel free to extend a gratuity as a result of your experience. Gratuities are accepted in the form of cash or credit card.

I do understand that if I fail to shave my appointment will either be rescheduled (first or second notice) or will result in losing one session. All sales are final and non-refundable. However, exchanges can be made for any remaining credit towards other services we provide. Thank you!

LATENESS & CANCELLATION POLICIES

I do understand our lateness, cancellation, and rescheduling policy are as follows:

Please arrive at least 5 minutes before your scheduled time. Delayed arrival will limit the time of your experience, reducing the effectiveness of your treatment and the expectations of your visit. In consideration of other guests, service time will not be extended for delayed arrivals.

As we are by appointment only, kindly give 24 hours advanced notice from your scheduled appointment time to cancel or reschedule.

Failure to provide such notice will result in a $30 fee for standard services or a $60 fee for full body services being charged upon your visit. If you do not agree to pay the fee your appointment will be rescheduled in six weeks from the date of your cancellation which will result in losing one session.

I duly authorize Sixth Avenue Laser Spa to perform the Soprano Ice, Vertex Lasers laser hair removal procedure, and any other measures, which in their opinion, may be necessary.


I understand the Soprano Ice and Vertex Lasers laser system is intended for hair removal and that clinical results may vary with different skin types, hair color, and body location. I understand there is a possibility of rare side effects, such as scarring and permanent discoloration; as well as short-term effects, including redness, mild burning, blistering, temporary bruising and discoloration of the skin, such as hypo pigmentation (decrease in skin pigment) or hyper pigmentation (increase in skin pigment). These effects have been fully explained to me.

I fully understand and I am aware that if I am taking any medication(s)/antibiotics that cause photosensitivity, I will be exposing myself to the risk of getting scarred or burned while undergoing my laser hair removal treatments.

I understand that laser hair removal is not 100% permanent and is in fact a reduction of up to 90%.

I understand that to achieve maximum results the protocol prescribed should be adhered to. The treatment schedule is designed to maximize the results during treatment of each hair cycle. If for any reason the schedule cannot be adhered to, I understand that the total percentage of hair loss could be affected. In addition, hair follicles that are dormant now may become active during or after my treatment program and additional treatments may be necessary. I also understand that I will have to pay for these additional treatments.

I understand that treatment by the Soprano Ice, Vertex Lasers laser hair removal system involves a series of treatments and 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.[inital] 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 I will inform Sixth Avenue Laser Spa if I become pregnant in the future so I can stop all laser treatments immediately.

I confirm that I have not taken Accutane within the last 6 months and that I do not have a pacemaker or internal defibrillator.

I understand that taxes and gratuities are not included in any service I purchase. I do understand that gratuities are based on regular single session prices and not package or discounted prices.

I understand that I must stop tweezing, waxing, bleaching, using depilatories or any substance/medication that will damage the hair follicle. I understand I need to FULLY shave (to the skin level) the areas that are to be treated at least 2 to 3 HOURS before of my scheduled appointment time and failure to do so will result in rescheduling of the appointment or the loss of a session. DO NOT SHAVE ON A DRY SKIN.

I understand excessive sun exposure needs to be avoided two weeks before and two weeks after each treatment. For optimal results, I should attempt to maintain the same skin tone throughout the treatment process. Sun exposure, tanning bed exposure or the use of tanning creams could result in a less effective treatment and the technician choosing not to perform the treatment.

I understand that each appointment time is blocked off for individual treatments and in order to avoid a cancellation charge of $30 or $60 (depending on areas), I will give at least 24 hours advance notice to cancel or reschedule so that appointments will be available for others.

I understand that all sales are final and non-refundable. However, exchanges may be made for any remaining credit toward other services we provide.

I have read and understand this agreement and all my questions have been addressed and answered to my satisfaction. I consent to the terms of this agreement. 

First Clients Name

First Name*

Middle Name

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Second Clients Name

First Name*

Middle Name

Last Name*
Second Clients Date of Birth*
Third Clients Name

First Name*

Middle Name

Last Name*
Third Clients Date of Birth*
Fourth Clients Name

First Name*

Middle Name

Last Name*
Fourth Clients Date of Birth*
Fifth Clients Name

First Name*

Middle Name

Last Name*
Fifth Clients Date of Birth*
Sixth Clients Name

First Name*

Middle Name

Last Name*
Sixth Clients Date of Birth*
Seventh Clients Name

First Name*

Middle Name

Last Name*
Seventh Clients Date of Birth*
Eighth Clients Name

First Name*

Middle Name

Last Name*
Eighth Clients Date of Birth*
Ninth Clients Name

First Name*

Middle Name

Last Name*
Ninth Clients Date of Birth*
Tenth Clients Name

First Name*

Middle Name

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

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Medications
What oral medications are currently taking?*
Birth control
Antibiotics
Hormones
Antidepressant
Retinol
Other

Please write down the name of the medication you are currently taking
Have you ever used Accutane?*
No
Yes

What topical medications or creams are you currently using? (Such as Retin-A) *
Have you ever had laser hair removal before?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks IN THE AREAS THAT WILL BE LASERED?*
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you used any methods of self-tanning within the last two weeks?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes
Female Clients Only
Are you currently pregnant or trying to get pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER / MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.Click to customize text


How were you referred to Sixth Avenue Laser Spa?

Your occupation
which of the following describes your skin best?*

MEDICAL HISTORY

Are currently under the care of a physician?*
No
Yes

*If yes, please specify your health concerns
Are currently under the care of a dermatologist?*
No
Yes

*If yes, please specify your dermatology concerns
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
HIV/AIDS
Frequent Cold Sores
Keloid Scarring
Skin Disease / Skin Lesions
Seizures
Hepatites
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Active Infections
Yeast Infection

Please list your other health concerns here

Please insert coupon code if any
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*

Phone*
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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