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IPL Photofacial / Skin Rejuvenation Consent Form

     I understand that multiple treatments are recommended, usually at least 3.

     I consent and authorize the staff at laser luxury to perform treatments on me. Light can be used effectively to destroy targets located in the skin with minimal damage to the surrounding tissues. Light is used to lighten, fade or remove photo damaged skin in a non-ablative manner, a procedure known as photo rejuvenation. Visible signs of photo damage include wrinkling, large pores, coarse skin texture and pigmented alterations.

     Phototherapy, despite its high levels of efficacy and safety is not free of side effects. Arrhythmia redness and swelling of the treated area can occur but usually subside within a few hours, but can last up to seven days or longer. Irritation itching and or mild burning sensation or pain similar to a sunburn may occur within 48 hours of treatment. Pigmentation changes such as hyperpigmentation and hypo pigmentation of the skin in the treated areas can occasionally occur. Mostly it is transient, lasting up to six months but in rare cases it can be permanent. Most cases of hypo or hyperpigmentation occur in people with darker skin or when the treated area has been exposed to sunlight before or after treatment. Occasionally these pigmented changes can occur despite appropriate protection from the sun. Scarring which can be hypertrophic or even keloid can occur. Other known complications of this procedure include blistering, reddening, pinpoint pitted scars, bruising, superficial crusting, burns, pain, and infections. These side effects are usually temporary, lasting for five to 10 days but can be permanent as well. The skin at or near the treatment site may become fragile. If this happens, makeup should be avoided in the area should not be rubbed, as this might tear the skin. A blue purple bruise may appear on the treated area, which might last for 5 to 15 days. As the bruises fade, there may be a rust-brown discoloration of the skin, which fades in one to three months or longer. Additionally, there is a known and expected loss of hair in the treated areas. In a very small percentage of people there's new hair growth in the surrounding areas being treated. Even though appropriate measures are taken to reduce side effects, they cannot be completely eliminated in every case.

       I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume these risks. With this in mind, I am choosing this non invasive treatment for vascular and or pigmented lesions and other indicated skin conditions. Eye damage can occur from the light and therefore protective eyewear must be worn during all phototherapy sessions. I have read and understand the pre and post treatment instructions. I agree to the follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of scarring, and other side effects and complications such as hyperpigmentation, hyperpigmentation and other skin textural changes. I understand that this examination is not meant to replace the necessity for a complete dermatological examination.

      Photographs: I give permission for my photographs to be used to help document my treatment course. Complete confidentiality will be maintained. No guarantee, warranty, or assurance has been made to me as the results that may be obtained. I am aware that the follow-up treatments may be necessary for desired results. Most patients require a number of treatments over several months with gradual results occurring over this time.  Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. No refund will be given. I understand and agree that all services rendered to me are charged directly to me and then I am personally responsible for the payment and any fees from missed appointments or cancellations within 24 hours. I give consent for my card on file to be charged in this event. The nature and purpose of the treatments have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I release the owner, staff, and technicians from liability associated with this procedure. I certify that I am competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon all legal representatives.

I Agree

April 28, 2025

First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
First Client Information

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
No
Yes
First Client Signature*
Second Client Name

First Name*

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

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
No
Yes
Third Client Name

First Name*

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

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
No
Yes
Fourth Client Name

First Name*

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

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
No
Yes
Fifth Client Name

First Name*

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

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
No
Yes
Sixth Client Name

First Name*

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

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
No
Yes
Seventh Client Name

First Name*

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

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
No
Yes
Eighth Client Name

First Name*

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

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
No
Yes
Ninth Client Name

First Name*

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

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
No
Yes
Tenth Client Name

First Name*

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

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
No
Yes
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.
Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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

List any Current Medications

Allergies
Recent sun exposure?*
No
Yes
Have you used any Retinol, Tretinoin, AHA, or other anti aging creams?*
No
Yes
Have you used any antibiotics in the last 2 weeks?*
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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