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Laser Treatment Consent Form

This is an informed consent document which has been prepared to help inform you about laser and light based treatment procedures of skin, risks, and alternative treatments. 

Please read this information carefully and completely before you sign the waiver and consent to receive laser treatment at Ease Medspa & Wellness Group.  

We use FDA approved advanced laser technology for the following treatments: Fine & deep lines & wrinkles, Photo rejuvenation, Acne scars, Stretch marks, Age spots, Sun damage.

Pre & Post Care Instruction:

Pre-treatment care:

  • Treatment area needs to be fully washed off and has no makeup, foundation, creams, etc.
  • Avoid the sun exposure or tanning booths for 4-6 weeks prior to treatment.
  • We do not recommend to have laser treatments if you are on medications such as Accutane, Retin-A, Gold Therapy etc, at present or within the past 6 months. These medications and several others, can make your skin susceptible to damage from the laser. The list of the aforementioned medications is available upon request.
  • Laser treatments cannot be given during your pregnancy.
  • If you have a history of herpes or cold sores, you may need antiviral medication. This medication should be started one day before laser treatment and continued for one week after treatment.

Post-treatment care:

  • There may be redness or swelling around the treated area. The skin will be sensitive and feel similar to a sunburn, treat the area gently by keeping the skin moist with either Aquaphor Healing Ointment or Aloe Vera Gel. If any blistering or scabbing develops, switch to Bacitracin Ointment and call the office. 
  • ​Keep the treatment area clean; Use tepid water for bath or shower with gentle wash.
  • If your face was treated, your skin will be extra-sensitive to heat. Keep away from the oven for 24 hours, and maintain a cool water temperature when taking a shower or bath
  • Avoid sun exposure for at least 3 weeks after treatment. Protect the area with a sunscreen of higher SPF, and protect the skin from developing hyper-pigmentation marks.
  • Do not pick, rub or scratch the area. Avoid any irritating medications or chemicals, such as Retin-A, Benzoyl peroxide, glycolic acid or astringents until the skin returns to normal.
  • After the treatment, the treated area may become pink, red, inflamed, or even blistered and may last several hours to several days, apply the ice, cooling gels, Hydrocortisone or Neosporin to relief. Do Not allow ice packs or ice into direct contact with the skin.
  • The treated area should be ready for the next session in about 4-6 weeks.

Consent to Perform Laser Treatment:

I understand that the service requested to be performed on me by Ease Medspa & Wellness Group is purely elective, and that the following problems may occur with the laser treatment:

  1. Short term effects may include but not limited to: Pain, swelling, red rush/bumps, pigment changes, temporary bruising, blistering or scarring, or unknown risks. Avoid sun exposure before and after treatment as exposure to the sun may intensify the pigment changes. It is rare that a change is permanent. 
  2. 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, also known as activation of cold sores. This applies to both individuals with known or un-known history of herpes simplex virus infections in the mouth area. Please inform us if you have ever had a problem with cold sores. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary. This reactivation can be avoided by taking an Anti-viral prior to the procedure.
  3. I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times. 
  4. I confirm that I have not taken Accutane within the last 6 months, and that I do not have a pacemaker or internal defibrillator. 
  5.  I confirme that I am not on antibiotics at this time.
  6. I confirm that I am Not pregnant at this time, and I will inform Ease Medspa Wellness if I become pregnant in the future so I can stop all laser treatments. 

Acknowledgment:

  • 24-hour Cancellation & Rescheduling Policy: I do understand that my appointment is one-on-one service and it is my responsibility to remember the appointment dates and times. I must Call, Email or send Message at least 24 hours prior to my designated appointment if I need to Reschedule or Cancel. 
  • No Show Policy: I understand that if I miss my appointment without canceling 24-hours in advance, it will be recorded as a “No Show” in my file. 
  • I do understand the 24-hour policy, and I agree to pay the appropriate fee of $30 if I fail to cancel or reschedule 24 hour in advance. The same rule applies to No Show appointment.
  • I do understand all appointments have been designed with appropriate time for each client.  Unfortunately that late arrivals will Not receive an extension of scheduled service time, and the client will be responsible for the rescheduling fee if appointment is not available at a later time on the same day. I understand that I'll expect the waiting time if I arrive late. 
  • No Refund: I do understand all sales are final and not refundable. 
  • No Guarantee: I understand that there is No guarantee can be made concerning the results of the treatment. Optimal results are achieved with a series of treatments, and the total number of treatments will vary between individuals. 
  • Taxes and Gratuity: I understand that Taxes and Gratuity are not included in the cost of the service. Industry standard is 15-20% of the original price for gratuity. Gratuity in Cash or Venmo is always appreciated!
  • I acknowledge that Pre & Post-procedure instructions have been provided to me by Ease Medspa & Wellness and I understand all such instructions, it is 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. 

 

By signing this consent form, I understand it is valid for all of my future laser treatments at Ease Medspa & Wellness Group, and I do understand it is my responsibility to inform the staff  if any medical or prescription changes. 

I confirm that my questions regarding laser procedure including the benefits and potential risks, side effects, possible complications associated with laser treatments have been answered satisfactorily. I understand the laser procedure and accept the risks. I, and any of my heirs, executors, representatives or assigns hereby release Ease Medspa & Wellness Group Inc. from any and all injuries, actions, causes of action, suits, damages, judgments, claims, and demands whatsoever, in law or equity, while on the premises during the laser treatments performed by any practitioners of Ease Medspa & Wellness Group Inc.

Dated: January 26, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
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.
Parent or Guardian's Name

First Name*

Last Name*

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

Client Questionnaire

Is your skin tanned on your treatment area(s)?*
No
Yes
Which laser treatment(s) would you be interested in?*
Laser Genesis
Laser Pigmentation Removal
Laser Hair Re-grow
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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