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SARAH LASER MEDSPA

Laser Hair Removal Consent Form 

ACKNOWLEDGMENT, WAIVER, AND CONSENT TO RECEIVE LASER HAIR REMOVAL PROCEDURES. DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS. 

Informed Consent

The purpose of this Informed Consent is to help you decide whether a laser hair removal (LHR) cosmetic procedure is right for you and to help you make an informed decision to undergo this procedure. This Informed Consent gives you general information about LHR cosmetic procedures, explains other treatment options, and identifies the benefits, risks, side effects and possible complications associated with LHR procedure. 

Laser Hair Removal Procedure

LHR is a non-invasive laser treatment designed to remove unwanted hair from all parts of the body. We offer different types of laser wavelengths, Alexandrite Laser and ND-YAG Laser (EpiCare System). The EpiCare system is the most sophisticated and technologically-advanced FDA approved Alexandrite (755nm) laser and Nd-YAG (1064nm) laser on the market today – ensuring the highest levels of efficacy.

As an Alexandrite Laser, it produces a 755 nm wavelength laser beam that most strongly targets melanin in the hair shaft while safely avoiding injury to the surrounding tissue. Our EpiCare Duo system provides a high powered Nd: YAG Laser that produces a slightly longer wavelength at 1064 nm. With it, we can safely and effectively treat individuals with very dark or tanned skin. 

Alternative Procedures

Laser Hair removal is a voluntary cosmetic procedure which is not necessary or required. Other Alternatives for hair removal practices:

  • Electrolysis
  • Waxing
  • Plucking
  • Threading

Contraindications of Laser Hair Removal

This treatment may NOT be performed for anyone with the following contraindications pertain to:

  • Pregnancy and nursing
  • Accutane (must discontinue use of product 6 months before beginning treatment)
  • Use of photosensitive medications (i.e. Antibiotic, Retinoids or other Acne medications, Antihistamines, Cancer chemotherapy drugs and other cancer drugs, Diabetic drugs, Statins, Malaria medications, Cardiac drugs, St. John Wort etc.) may cause an increased risk of side effects to the laser (must discontinue use of product 4 weeks prior to initial treatment)
  • Epilepsy or those who have a history of seizure
  • Poorly controlled Diabetes
  • Current (active) skin cancer within one year or pre-malignant moles in the treatment area. A medical clearance letter is required.
  • Active sores or rash (psoriasis, eczema) in the area to be treated.
  • Skin disorder such as keloids or abnormal wound healing 
  • History of melanoma, active or inactive anywhere on the body
  • Recent (within 1 months) surgery, laser resurfacing or deep chemical peels in the treatment area
  • Severe medical disorders such as poorly controlled heart conditions
  • Chemo or radiation therapy (letter of clearance from your physician is required)
  • Pacemaker, internal defibrillator, and any internal electrical devices
  • Any internal metal device, i.e. surgical screws, pins, plates, or implants, in the area to be treated (no treatment if any device is superficially in the body area to be treated)
  • Aids, HIV positive or use of immunosuppressive drugs (a letter of clearance from your physician is required)
  • Multiple sclerosis (a letter of clearance from your physician is required with confirmation that the area to be treated is not numb)
  • Immune disorders such as Scleroderma, Lupus, Porphyria, Sarcoidosis, and others
  • treatment over moles or lesion of any kind
  • Treatment over tattoos, port wine stains, under the eyebrows, or any orifice
  • Bleeding problems or use of blood thinners
  • History of disease stimulated by heat, such as recurrent Herpes Simplex in the treatment area. You may treat this area only following a prophylactic regime. 

TANNING over the course of treatments is not recommended and can cause a number of complications. Scheduled treatment may be postponed if the patient is tanned. Tanning and sun exposure should be avoided 2 weeks before and 2 weeks after each treatment. Sunblock with SPF 30 or higher should be used on treated areas during the course of laser treatments. It is the patient's responsibility to inform the treatment provider if the skin is darker than when treatment was first started as well as any medical or prescription changes during the course of treatments. Improper post-treatment care may increase the chance of any complications. 

 

Risks and Complications

  • There is a risk of scarring.
  • Short term effects may include reddening, mild burning, temporary bruising or blistering, hyper-pigmentation (browning), and hypo-pigmentation (lightening) has also been noted after treatment. These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Avoiding sun exposure before and after the treatment reduces the risk of color change.
  • Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. 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.
  • Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.
  • Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. Systemic reactions (which are more serious) may result from prescription medicines.
  • As with all LHR procedures, some re-growth of hair may occur after treatment sessions are completed. 
  • I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times. 

Pre Consultation Checklist

  • Sarah Laser Center Medspa utilizes the latest technology EpiCare Duo, the Nd Yag 1064 and Alex 755 with cold air system by Cryo6 by Zimmer. 
  • Clients have to be shaved completely. Each session has to be every 6 to 8 weeks.
  • Laser hair removal is a medical procedure, not wax. Laser hair removal kills follicle. Lasers can only kill ACTIVE hair follicle.
  • Should start to see results 6 weeks after 2nd treatment, and hair will grow in patches because of multiple hair cycles. 
  • With every visit you will lose 5-10% of hair. After 6 to 8 treatments you will have about 70-90% of hair loss. 
  • Please, tell the technician about your last sun exposure of tanning due to high risk of burn with increased setting and sun exposure. 
  • Notice - Face and Lower Arms, are hormonal areas, sometimes you need more than 8 sessions to see results up to 70-90% of reduction.
  • Hair removal requires a series of treatments. The number of treatments depends on the body location and type of hair. 

Pre-Procedure Instructions

6 months before:

  • Avoid Accutane

4 weeks before:

  • No waxing, plucking or using depilatory (hair removal cream)
  • Avoid photosensitive medications (i.e. Antibiotic, Doxycycline, Tricyclic antidepressants, Quinidine, Amiodarone, St. John Wort etc.)
  • Avoid other laser treatments/ Microdermabrasion/ Chemical Peels/ Botox/ Filler on the treatment site

2 weeks before:

  • Avoid sun exposure, tanning beds, creams or spray
  • Avoid skin irritants (i.e. Products contain tretinoin, retinol, benzoyl peroxide, glycolic/salicylic acids, astringents, etc.)
  • Avoid Anticoagulants

24 hours before:

  • If you have a history of Herpes Simplex Virus or cold sores, you must premeditate one day prior to treatment to prevent further outbreaks.

Day of treatment:

  • The area to be treated must be CLEAN SHAVED the day of your treatment.
  • Remove any lotions, body oil, perfume, make-up, deodorants and jewelry in the areas to be treated prior to treatment.
  • Wear loose fitting clothing that will leave the treatment area exposed and easily accessible for treatment. Tight or rough clothing may cause you to feel uncomfortable if the skin becomes sensitive after treatment.
  • You may feel a slight prickling or stinging. Some people feel a rubber band snapping onto the skin. 

If you are pregnant/breastfeeding, you are NOT a good candidate for laser. 

Post-Procedure Instructions

It is IMPORTANT that you follow all post-treatment instructions carefully because, during the healing process, there is a slight possibility that the treated area can become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually a temporary condition; however, on a rare occasion, it can be permanent. Please call your doctor promptly if complications develop after the procedure.

  • Immediately after treatment, there should be erythema (redness) and edema (swelling) at the treatment site which may last 2 hours to several days. The erythema may last up to 2-4 days. The treated area can feel like a sunburn for several hours after. 
  • It's recommended to use an ice pack post-treatment to provide comfort if the treated area is extremely warm and it is typically needed within the first 20 minutes after the treatment. 
  • It's recommended to apply Aloe Vera or Hydrocortisone 1.5% post-treatment 3 times daily for a soothing cooling effect. 
  • Rarely, minor epidermal blistering may occur in which case antibiotic ointment may be applied twice a day to the affected areas.  DO NOT pick at these areas, as this may result in infection or scarring. If this should happen, please contact our office immediately and our aesthetician will give you further instructions.
  • UNDERARMS: wait a few hours until any sign of redness has vanished before you use deodorants. 
  • FACE: wait a few hours until any sign of redness has vanished before you put on makeup. NO skin irritants (i.e. glycolic acids, retinoids, etc.) for 7 days after treatment.
  • Avoid any activities that will cause sweating (i.e. exercising, hot shower, hot saunas etc.) for a minimum 12 hours.
  • Avoid sun exposure 2 weeks after laser treatment 
  • Apply sunscreen daily. It should be at least SPF 30 protects UVA/UVB and contains the physical blockers zinc oxide and titanium oxide. It is recommended to use SPF 50 during summer time for the first two weeks after your laser treatment.

IMPORTANT TIPS:

  • NO plucking, waxing, using a depilatory or undergo electrolysis in between treatments.
  • It may take 2-3 weeks for the dead hairs to fall out from the follicles. During the shedding phase, hair may look like it's growing, but it is actually shedding out. It's recommended that you gently exfoliate the treated area starting from Week TWO, 2 to 3 times per week to help the dead hair fall out which will help eliminate the ingrown hairs. Applying moisturizer after exfoliating will help skin replenish. 

Follow Up

  • Recommended treatment intervals: Every 4-6 weeks for facial areas, every 6-8 weeks for body areas.  

 

Please initial here that you have read, understood and agreed to the following information:

 

CANCELLATION POLICIES

I do understand the 24-hour cancellation notice required, and agree to pay the appropriate fees if I do not cancel or reschedule within 24 hours of my appointment date and time. Cancellation fee of $45 will be applied if I fail to cancel or reschedule within the specific time frame. The same rule applies to NO SHOW appointments. As a courtesy, we will send an email / text message reminder to confirm your appointment date. Must confirm on all follow-up appointments.   Please understand that it is your responsibility to let us know if you need to cancel or reschedule to avoid the cancellation fee.

 

ONLINE PROMOTION VOUCHER POLICY

NEW CLIENTS ONLY; ONLY LIMIT TO ONE VOUCHER PER CLIENT PER SERVICE TYPE.

LIMIT 1 (one) PER PERSON, MAY BUY 1 (one) ADDITIONAL AS GIFT; GIFT MAY BE USED BY NEW CLIENTS ONLY.

VALID ONLY FOR OPTION(S) PURCHASED, if the desired treatment is not the right option purchased, the client can exchange or upgrade the package voucher, or request refund through online merchants.

All treatments MUST be used on the SAME AREA and on the SAME PERSON.

 

Pricing and Promotion

We are committed to continuously expanding our services to ensure we bring you the latest and greatest technology. Although we make every effort to keep our website and spa menu updated accordingly, please note that prices, services, and products are subject to change at any time without notice. Special offers and discounts may not be combined and vouchers purchased from 3rd party vendors (Groupon, etc) are limited to 1 per client. When presented with more than one discount opportunity we will automatically give patients the discount of greater value at the time of purchase. 

 

Refund Policy

I do understand all sales are final and non-refundable. There will be no refund or reimbursement to the unfinished package(s), voucher, or deals if you become ineligible for laser treatment or physically unable to continue the treatment within the stated period. However, exchanges may be made for any remaining credit toward other services we provide.

 

Tipping/Gratuity

I do understand that TAXES/GRATUITY are not included in any service I purchase. Tipping is not mandatory but it is customary in most circumstances for service.  It is common practice to tip 10%-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. 

 

Result Expectation

  • I do understand that laser hair removal is NOT 100% permanent but a reduction of 70 to 90% after 6 to 8 sessions. Ideal (light skin/dark coarse hair) candidates can usually achieve 70%-90% reduction with an uninterrupted of 6 to 8 treatments. 
  • I do understand laser hair removal IS NOT EFFECTIVE on BLONDE and GREY hair.
  • Clinical results of LHR may also vary depending on individual skin sensitivity, skin type, hair type, hormonal levels, medical condition, and hereditary influences. Therefore, some patients may experience limited results and/or may need indefinite ongoing treatments. 

I do understand the result may vary depending on skin tone, hair color, and any medical / health conditions. Future hormonal changes may cause additional hair growth, and is recommended to come back for re-examination every 3 to 4 months after the initial course of treatment. 

 

Tweezing/Plucking/Waxing/Bleaching/Using Depilatories, etc

Tweezing, waxing, threading, and bleaching treatment areas must be avoided 4 weeks before beginning treatment because these methods will impact the hair follicles and may result in less effective treatments. Hormonal imbalance, PCOS, Hirsutism, pregnancy, menopause, and other endocrine conditions can affect the treatment outcomes.

 

Photosensitive Medication

I do understand that photosensitive medication (i.e. Anit-biotic, Accutane, Retin-A, St John Wort etc.) will dramatically increase the chance of the adverse reactions including but not limited to: redness, swelling, blistering, burns, itching, discomfort, and discoloration (hyper- and hypo- pigmentation), and that scarring, while rare, is also possible. I do understand that it's my sole responsibility to inform my technician about any changes in my current medical conditions prior to any of my laser treatments. 

 

Sun Exposure

I do understand that excessives sun exposure needs to  AVOID two weeks before and two weeks after each treatment. For optimal results, I should attempt to maintain the same skin tone throughout the course of treatments. Sun exposure, tanning bed exposure or the use of tanning creams could result in a less effective treatment and a higher chance of adverse skin reactions and the technician may reserve the right not to perform treatments. 

 

I understand that this consent form is valid for all future laser hair removal treatments performed, and I will alert the staff if there are any changes to my medication, medical history, or if I become pregnant. 

 

By signing below, I certify all information is true and correct to the best of my knowledge, understand and agree to the following:

  • I certify that I am not Pregnant and I am not planning to get pregnant during the course of the treatment.
  • I certify that I have not taken Accutane within the past six months.
  • I certify that I have not taken Antibiotic within the past four weeks.
  • I certify that I do not have a Pacemaker or internal defibrillator.
  • Have the right to consent to or refuse any proposed procedure at any time prior to its performance.
  • I certify that the information contained in this Informed Consent was explained to me using terms I could understand, and all my questions and concerns have  been answered. After reviewing all the information provided to me about cosmetic procedures and reviewing my health status, I believe I am a good candidate for Laser Hair Removal procedure.
  • I acknowledge and accept the risks inherent in the Laser Hair Removal Procedures. I voluntarily assume the risk of possible complications and side effects which may arise from the Treatments set forth herein; and any of my heirs, executors, representatives or assigns hereby release Sarah Laser Center Inc. from any and all claims, liabilities for personal injury, and property damages of any kind sustained while on the premises, during the treatments set forth herein by any employees or representatives of Sarah Laser Center Inc.
  • I confirm that I have read the post-treatment instructions provided by Sarah Laser Center Inc. and I understand that it's my responsibility to follow these instructions and that my failure to adhere to these recommendations may result in complications and contraindications for which I am fully responsible.
  • I certify that I have been advised of the pre-treatment instructions, post-treatment healing process, the possible risks relating to treatment, and have been given the opportunity to ask and have answered all questions. I agree to follow all aftercare instructions, and to notify Sarah Laser Center Inc. of any concerns or difficulty in healing, along with any updates in my medical information. Further, I will not hold Sarah Laser Center Inc. liable for any omissions or post-treatment reactions.
  • I certify that I have read the entire above Informed Consent and believe that Sarah Laser Center Inc. has adequately explained the risks of this treatment, alternative methods of treatment, and possible benefits from this treatment, and I hereby consent to the Laser Hair Removal treatment to be performed by the technicians of Sarah Laser Center Inc. Considering that I have been informed that certain medical conditions prohibit the patient from the treatment, I have provided a full and truthful medical history and a truthful and accurate account of my medications to this office. Having been apprised of all the above, I have signed this Consent Form and authorize the subject treatment.

 

 

Date: April 18, 2021

Please select who will be receiving consult/treatment...
AdultMinor
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First Patient's Name

First Name*

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

Age: *

Occupation *
How did you hear about us?*

Other

Acknowledgement:

I certify that the preceding medical, personal 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 procedure. 

First Patient's Signature*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Please answer the following questions
Please specify your genetic origin:*
African American
Asian- Chinese, Japanese, Korean etc.
Asian- Indian
Caucasian
Hispanic/Latino
Mediterranean
Middle Eastern
American Indian, Alaska Native
Other
Have you received any Laser Hair Removal treatment in the past?*
No
Yes

If yes, please describe how many sessions conducted in the past and when was the last time? (if no, please notated "NONE") *

Please specify the treatment area(s) for your first visit. (i.e. underarms) *

If you have a prepaid package, please provide voucher number: (i.e. 1234567) *

Please specify what other areas you would like to consider in the future. (if no, please notated "NONE") *
For Facial Treatments Only:
Have you used Retin-A, Renova, Differin, or Tazorac in the past two (2) weeks?*
No
Yes
Have you used glycolic acid/AHA home care products in the past four (4) weeks?*
No
Yes
Have you had any of the below skin treatments on the face in the last four (4) weeks?
Chemical Peels
Laser Resurfacing
IPL Photofacial
Microdermabrasion
Botox/Filler
Laser Hair Removal
Microneedling
Dermaplaning
Skin Typing

Please answer the following questions by selecting the number which BEST describes you.

Eye Colour*
0. Light colours
1. Blue, gray or green
2. Hazel/Light Brown
3. Dark Brown
4. Black
Natural Hair Colour*
0. Sandy red
1. Blond
2. Chestnut or dark blond
3. Brown
4. Black
Your natural skin colour (unexposed area)*
0. Reddish
1. Pale
2. Beige and olive
3. Brown
4. Dark Brown
What happens if you stay in the sun too long?*
0. Painful, redness, blistering and peeling
1. Blistering followed by peeling
3. Burn, mild peeling
3. Rare burn
4. Never had burns
Do you turn brown after several hours of strong sun exposure?*
0. Never
1. Seldom
2. Sometimes
3. Often
4. Always
To what degree do you turn brown?*
0. Hardly or not at all
1. Light color tan
2. Reasonable tan
3. Tan very easily
4. Turn brown quickly
How does your face react to the sun?*
0. Very sensitive
1. Sensitive
2. Normal
3. Resistant
4. Never have a problem
How often do you tan?*
0. Never
1. Seldom
2. Sometimes
3. Often
4. Always
When was your last tan?*
0. +3 months ago
1. 2-3 months ago
2. 1-2 months ago
3. A few weeks ago
4. A few days ago
Which of the following best describes your skin type?*
I Always burns, never tans
II Always burns, sometimes tans
III Sometimes burns, always tans
IV Rarely burns, always tans
V Brown, moderately pigmented skin
VI Black skin

Reference:

  • Skin Type I: Red or pink undertone, blue/green eyes, blond/red hair, prone to freckles, always burns, never tans. Example: Very pale Caucasian, or Albino etc.
  • Skin Type II: Subtle beige undertone, blue or brown eyes, light or dark hair, burns easily, tans minimally. Example: Fair-skinned Caucasian etc. 
  • Skin Type III: Golden honey tone, green/blue or brown eyes, dark hair, tans after initial burn. Example: Darker Caucasian, European, Asian, Hispanic etc.
  • Skin Type IV: Olive skin tone, brown eyes, dark hair, burns minimally, tans easily. Example: Mediterranean, European, Asian, Hispanic, Native American, Middle Eastern etc. 
  • Skin Type V: Brown skin tone, brown eyes and dark hair. Rarely burns, tans dark easily. Example: Hispanic, Afro-American, Middle Eastern, Asian, African etc. 
  • Skin Type VI: Dark brown skin tone, dark brown eyes and black hair. Never burns, always tans darkly. Example: Afro-American, African, etc.

(* Fitzpatrick, T.B. (1988) The Validity and practicality of sun-reactive skin types I through VI, Arch Dermatol 124; 869-871)

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*

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

Age: *

Occupation *
How did you hear about us?*

Other

Acknowledgement:

I certify that the preceding medical, personal 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 procedure. 

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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