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Laser Treatment Consultation Form

Laser Treatment Consent Form

Please read and initial by each paragraph:

I am 18 years of age or older, or I am accompanied by a parent or legal guardian who will consent for me to have this treatment. 

I acknowledge that the laser is a device that produces an intense but gentle burst of light. With this light, there is a minimal amount of risk. These risks (listed below) are typically associated with prolonged exposure to sunlight or use of a prohibited medication. 

I understand that the following are possible risks and complications of this procedure including but not limited to:

  • Purpura (red-purple discoloration, bruising)
  • Itching (hive-like response which lasts 2-3 hours to 2-3 days)
  • Herpes simplex virus activation (only if you are already a carrier)
  • Burns, blisters, scabbing, crusting, skin color and /or textural changes Hyperpigmentation (darkening of the skin; transient or long term)
  • Hypopigmentation (lightening of the skin; transient, long term or possibly permanent) Scarring (rare, possibly permanent)

I understand that my eyes will be covered with laser-specific safety eyewear or an opaque material to protect them from the intense light. My eyes will be closed and I will not attempt to remove the eye protection during treatment. 

I understand that complete clearing of my spider veins, brown spots, or redness may not be possible and will depend upon the type, age and color of the trouble spot. Multiple treatments may be needed for the best results. 

I understand that other methods of treating this condition will be discussed with me if I request, such that I may assess the risks and benefits of these alternative treatment methods. 

I understand I will be given complete instructions regarding after care of the treated area. It is important to follow aftercare instructions carefully to minimize the chance of incomplete healing, skin textural changes or scarring. This includes, but is not limited to, avoiding sun exposure and tanning. 

I have answered all questions about medical history and medications honestly and completely.

I understand I will be given the opportunity to ask questions about the procedure and the procedure will be discussed in detail with me. 


I have read and understood all information presented to me before signing this consent form.

Signature: 

Date: October 1, 2022

First Patient Name

First Name*

Last Name*

Phone*
First Patient Date of Birth*
First Patient Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
No
Yes
First Patient Signature*
Second Patient Name

First Name*

Last Name*
Second Patient Date of Birth*
Second Patient Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
No
Yes
Third Patient Name

First Name*

Last Name*
Third Patient Date of Birth*
Third Patient Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
No
Yes
Fourth Patient Name

First Name*

Last Name*
Fourth Patient Date of Birth*
Fourth Patient Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
No
Yes
Fifth Patient Name

First Name*

Last Name*
Fifth Patient Date of Birth*
Fifth Patient Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
No
Yes
Sixth Patient Name

First Name*

Last Name*
Sixth Patient Date of Birth*
Sixth Patient Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
No
Yes
Seventh Patient Name

First Name*

Last Name*
Seventh Patient Date of Birth*
Seventh Patient Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
No
Yes
Eighth Patient Name

First Name*

Last Name*
Eighth Patient Date of Birth*
Eighth Patient Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
No
Yes
Ninth Patient Name

First Name*

Last Name*
Ninth Patient Date of Birth*
Ninth Patient Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
No
Yes
Tenth Patient Name

First Name*

Last Name*
Tenth Patient Date of Birth*
Tenth Patient Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*

How did you hear about us?
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*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Please list past or present medical conditions, illnesses, or allergies:

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken:
Do you have a history of keloids/hypertrophic scars?*
No
Yes
Do you use sunscreen?*
No
Yes
Do you smoke?*
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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