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Laser Acne Consent Form

     Laser acne treatment kill bacteria that cause acne, aiding and preventing breakouts, speeding the healing of current acne blemishes and reducing the redness and irritation associated with acne.

     Over a series of treatments, most clients notice a faster healing time of existing acne lesions. Frequency and severity of acne lesions should subside as the treatments go on. As well, ongoing treatments can help to prevent acne breakouts and promote skin healing after breakouts by evening out skin tone and texture.

     Cooling of the skin surface helps ensure additional safety during treatment. This is no-downtime procedure.  Many patients return to normal activities immediately after treatment. Depending on the severity of acne, treatments are recommended 1 to 2 times a week.

       Additionally, during the course of treatments it is advised to have at least one Acne facial a month in between laser treatments to deep cleanse the skin during oils import extractions.

     Do not use any topical creams, retinol, retina, tretinoin, isotretinoin, benzoyl peroxide, antibiotics, or accutane. Please advise the staff of laser luxury of any medications you are on or of any changes.

      Avoid sun exposure during the course of treatment. Although rare, a possible side effect of any laser treatment is hyper or hypo pigmentation. I understand that there is a possibility of short-term effect such as reddening, swelling, scab formation, temporary discoloration of the skin, as well as the possibility of rare side effects such as burn, scarring and permanent discoloration. These effects have been fully explained to me. I understand that open, cystic acne may not be treatable by acne laser treatments.

      I authorized the staff at Laser Luxury to perform the acne laser treatments on me. I understand that results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre and post treatment instructions, and individual response to treatment. I understand that results are not guaranteed and that I may not see any results. I also understand that laser acne treatment involves a series of several treatments, including multiple treatments - sometimes per week, for several weeks and the payment structure for the packages has been fully explained to me.

     I also understand that there is a 24 hour $25 cancellation policy, I agree to pay this fee / have my card on file be charged should I miss my appointment or cancel / need to reschedule within the 24 hour. 

    I certified 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 understand that I should not pick, peel, scratch or scrub the skin before, after or while receiving laser treatments and that doing so will increase the risk of scarring, infection, discoloration or other adverse reactions to the skin.

     I confirm that I have informed the staff regarding any current or past medical conditions, disease or medications taken, as well as my past and planned exposure to sun, sun bed and self tanning creams.

     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.

      By signing below I indicate that I have read each statement above and that I fully understand each statement above and that I have consenting to laser treatment with laser luxury.

I Agree

April 18, 2025


First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
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 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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