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Informed Consent - Laser Veins Removal Treatment

 

IMPORTANT : Starting January 2019, in order to improve customer satisfaction and avoid miscommunication, we NO LONGER accept phone reservation or rescheduling. You can reach us directly by Text (551) 230-6569 or email us care@baredmonkey.com. Please save our phone number and email as point of contact. 

 

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

 

1. Laser Treatment Informed Consent

 

  • I authorize Bared Monkey MedSpa Inc to perform laser vein removal procedure on me.


  • I understand that the removal or lightening of dilated superficial veins is a procedure that involves using a laser. Some discomfort may be experienced during laser treatment. I understand that there is a possibility of rare side effects such as scarring or permanent discoloration. Other side effects such as swelling, blistering, crusting, or flaking of the treated area, may require one to three weeks to heal. Once any of these conditions have healed, the treated area may still be sensitive to the sun for an additional two to four weeks, or possibly longer in some patients. During the healing process, there is a slight possibility that the treated area can become either lighter (hypo-pigmentation) or darker (hyper-pigmentation) in color compared to the surrounding skin. This is usually a temporary condition; however, on a rare occasion, it can be permanent. It is IMPORTANT that I follow all post-treatment instructions carefully. *


  • I understand that the results from the treatment vary with each individual. The purpose of this treatment is to attempt to remove, fade, or significantly lighten the veins. This treatment is not a cure for vein disease, nor will it prevent further veins from developing. Multiple treatments may be necessary.

 

  • I understand that 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 50 or higher should be used on treated area during the course of laser treatments. It is my 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 chances of any complications.

 

  • I understand that If I am pregnant/breastfeeding, I am NOT a good candidate for laser. 

 

  

 


2. Contraindications

 

You may not be the best candidate for laser veins removal if any of the following contraindications pertain to:


  • Pregnancy and nursing
  • Use of Accutane (must discontinue use of product 6 months before beginning treatment)
  • Use of photosensitive medications (i.e. Anti-biotic, 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 before beginning treatment)
  • Epilepsy or those who have a history of seizures
  • 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.

 

 

3. Risks and Complications

 

All medical and cosmetic procedures are associated with certain risks and may result in complications. Possible risks and complications associated with laser hair removal procedure include:

• DISCOMFORT: Mild to moderate discomfort is typical during treatment. The treatment settings may be adjusted according to skin reactions and comfort levels

•  CRUSTING – multiple pinpoint crusts may appear. Antibiotic ointments or healing ointments should be applied. It is important I do not rub nor pick my skin which may otherwise lead to scarring

•  RED OR PURPLE SPOTS – broken capillary blood vessels may lead to transient “mini-bruising”. Sun avoidance is essential in that case

• REDNESS/SWELLING/BRUISING – Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.

• HYPERPIGMENTATION: (Changes in skin Color): – During the healing process, there is a slight possibility that the treated area may become darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, and it may last one to several months before normal pigmentation levels return. Hyperpigmentation is very rarely permanent. A skin-lightening product may be recommended to accelerate the recovery process.

• HYPOPIGMENTATION: (Changes in skin Color): – Lightening or loss of skin pigment is very rare. Transient hypopigmentation lasting several weeks has been reported following crusting/scabbing. Permanent hypopigmentation has not been reported; however, it is a possible adverse event, especially in clients with a history of vitiligo or pigmentary disorders.  

• BLISTERING: Blisters are not common, but have been reported. If blisters do develop, please contact us immediately for further instruction. 

• SCARRING – Scarring is a rare occurrence, but it is a possibility whenever the skin's surface is disrupted. Patients with a history of keloid scarring may develop complications and we don't recommend laser tattoo removal treatments.


 

6. Pre-Procedure Instructions

 

It is IMPORTANT that you follow all pre-treatment and post-treatment instructions carefully to minimize the chances of complications and achieve the optimum results from treatments. 

6 months before:

  • Avoid Accutane 

4 weeks before:

  • Avoid waxing, plucking, using depilatory (hair removal cream) or other hair removal practices.
  • Avoid photosensitive medications (i.e. Anti-biotic, 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, self tanner such as creams or spray.
  • Avoid skin irritants (i.e. Products contain tretinoin, retinol, benzoyl peroxide, glycolic/salicylic acids, astringents, etc.) 
  • Avoid Anticoagulants

24 hours before:

  • The area to be treated must be CLEAN SHAVED the day before your treatment. 
  • 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:

  • 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.
  • During your treatment you can expect slight discomfort, similar to a rubber-band snap on your skin. If you have sensitive skin, you may apply a topical numbing cream 30 minutes prior to treatment time in order for it to take effect.

 

 

Post-Procedure Instructions

 

Immediately after treatment, there should be erythema (redness) and edema (swelling) at the treatment site which may last several hours to several days. The treated area can feel like a sunburn for several hours after.

Please be advised that you may expect a certain degree of discomfort, redness, and/or irritation during and after treatment. If any discomfort or irritation persists, please notify the office.

  • It is helpful to elevate your legs for the first 48 hours. We also recommend wearing support hose for at least 72 hours after leg vein treatments.
  • After your treatment, it is common for the treated veins to remain visible for 3 to 6 weeks before dissipating. This is due to residual clotted blood in the vessel.
  • In some rare cases, the treated skin may blister. Do not scratch or open the blister—this could cause permanent scarring and/or infection. If blisters occur, please contact us immediately for further instruction. 
  • A red scab may form under the skin. It may appear for a few weeks and then will be reabsorbed by the body. This is supposed to happen and is a sign of successful treatment.
  • You can expect treated areas to remain somewhat red and swollen for the first 24 to 48 hours. In some cases, this may last up to 1 week.
  • It is possible to have pain from the treatment of larger veins for several days post-treatment. Tylenol and/or arnica are recommended for any discomfort.
  • Do NOT engage in vigorous aerobic activity such as running, hiking, or aerobic exercise for approximately 72 hours post-treatment.
  • It is advised to remain out of the sun for a minimum of 2 week. It is recommended that you use a 50 SPF sunblock for any sun exposure.
  • The skin of the treated areas may tend to itch. This is a sign of healing. Keep areas hydrated with moisturizer and apply hydrocortisone cream to itchy areas 3-4 times daily until itchiness subsides.
  • Bruising is another common side effect of laser treatment. Bruising is temporary and will dissipate within a matter of days or weeks depending on your individual healing process. Arnica is recommended if you have a tendency to bruise. Arnica helps reduce bruising and eases the soreness of bruising.

 

 


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

  • 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 Veins Removal procedure.
  • I understand that I am not allowed to have laser veins removal treatments without a written approval from a parent and/or legal guardian if I am under 18 years old.
  • I understand it's my sole responsibility to inform my technician about any changes in my current medical conditions prior to any of my laser treatments. 
  • I acknowledge and accept the risks inherent in the Laser Veins Removal Procedures. I voluntarily assume the risk of possible complications and side effects which may arise from the Laser Treatments set forth herein; and any of my heirs, executors, representatives or assigns hereby release Bared Monkey MedSpa and all its affiliated companies 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 Bared Monkey MedSpa and all its affiliated companies.
  • I certify that I have been informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision of to proceed is based solely on my expressed desire to do so. 


  • 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 Anti-biotic within the past four weeks. 
  • I certify that I do not have a pacemaker or internal defibrillator.
  • I confirm that I have read the pre-treatment and post-treatment instructions provided by Bared Monkey Laser Spa and all its affiliated companies 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 agree to receive text messages and emails from our appointment confirmation and promotional text message or email will be delivered to the phone number and email on this waiver. You can reply Stop to opt-out text message and/or click on unsubscribed in any email to cancel email communication. 
  • I certify that I have read the entire above Informed Consent and believe the Bared Monkey MedSpa and all its affiliated companies has adequately explained the risks of this therapy, alternative methods of treatment, and possible benefits from this treatment, and I hereby consent to the laser treatment to be performed by the technicians of Bared Monkey MedSpa and all its affiliated companies. Considering that I have been informed that certain medical conditions and medications prohibit the patient from laser therapy, 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.

 

June 13, 2024

 

 

 

 

 

 



Please select who will be participating...
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First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Gender
Patient Gender*
First Patient's Signature*
Patient's 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 or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail. By entering your email, you are agreeing to receive appointment comfirmation, promotional email from us. You can click on unsubscribed to opt-out in any communication emails.
How did you hear about us?
How did you hear about us?*
Friend Referral
Google
Yelp
Online Promotion Sites
Social Media
Others

If you are referred by a friend/family member, please write down his/her name:

Referral Program:

  • Refer ONE friend, get $10 store credits

  • Refer THREE friends, get a FREE lifetime membership

Feel free to check our referral program online for more information. 


Client Intake Form
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

Previous Laser Veins Removal Experience:

Have you received any Laser Veins Removal treatment before?*
No
Yes

If "YES", please specify how many sessions conducted in the past and when was the last time?
Patch Test
The patch test is a mini sample for you to gauge what your treatment will be like and how it will feel. A range of settings will be used in the patch test, tailored to your individual skin and hair type, until a good clinical endpoint is achieved. You will be able to feel a slight pinpricking sensation when the desired setting is achieved.The patch test is done two (2) weeks before your first full treatment so that any reactions (i.e. hyper or hypo-pigmentation, blistering etc.) have time to appear and your treatment plan can be adjusted if necessary, to ensure effective results with minimal side effects. A patch test is offered however it does not ensure a client will not have an adverse reaction to subsequent treatments. If waived, I release the technician from liability if I develop an adverse reaction to the laser hair removal treatment. Choose one or the other, not both:*
I waive (skip) the patch test
I consent to (go for) the patch test and I will schedule my first treatment 2 weeks later.
Females Only

You might be contraindicated to Laser Veins Removal if you choose "YES" to any of the following questions, please EMAIL us at care@baredmonkey.com for any assistance: 

Are you pregnant or planning pregnancy during the course of treatment?*
No
Yes
N/A
Are you breastfeeding?*
No
Yes
N/A
For Facial Treatments Only:

You might be contraindicated to Laser Hair Removal if any of the following conditions applied to you, please EMAIL us at care@baredmonkey.com for any assistance: 

Have you had any of the below skin treatments on the face in the last four (4) weeks? *
Chemical Peels
Laser Resurfacing
IPL Facial
Microdermabrasion
Botox/Filler
N/A
Have you had any of the below skin treatments in the treated area(s) in the last two (2) weeks? *
Glycolic Acid, Benzoyl Peroxide or Salicylic Acid
AHA Skin Products
Skin products contains Retin-A, Retinol, Differin, or Tazorac
N/A
Medical History Part I
Do you have any of the following medical conditions? (please check all that apply)
AIDS
Albanism
Active Acne
Bleeding Disorders
Diabetes
Endocrine Disorders
Epidermolysis bullosa
Heart disease
Hemorrhoids
Herpes 1&2
High blood pressure
Gold Theraphy
HIV
Hirsutism
Hormone Replacement
Implants
Kaposi 's sarcoma
Keloid scars
Lesions/Sores/Open wounds
Lupus erythematosus
PCOS
Port-wine stain
Precocious puberty
Psoriasis/Eczema (on the treatment site)
Porphyria
Pacemaker
Rosacea
Seizures/Epliepsy
Skin cancer
Severe histamine reactions
Skin Marks/ Moles/ Freckles
Tattoos/Permanent Makeup (on the treatment site)
Vitiligo
Medical History Part II

You might be contraindicated to Laser Hair Removal if you choose "YES" to any of the following questions, please EMAIL us at care@baredmonkey.com for any assistance: 

Have you taken Accutane in the past six (6) months?*
No
Yes

If "YES", please specify the date of last use.
Have you taken Antibiotics in the past four (4) weeks?*
No
Yes

If "YES", please specify the date of last use.
Have you exposure to sun/artificial tanning or used tanning spray/cream on the treatment area in the last two (2) weeks?*
No
Yes
Have you had any of the below hair removal practices on the treatment areas(s) in the last four (4) weeks?
Waxing
Plucking
Tweezing
Depilatories
Epilating
Electrolysis
Hair Bleaching
Do you have a history of bleeding coagulopathies or use of anticoagulopathies?*
No
Yes
Do you have skin cancer or precancerous lesions?*
No
Yes

If yes, please descript:
Do you have any active skin diseases or infection in the area to be treated?*
No
Yes

If yes, please descript:
Are you undertaking a course of treatment that may make your skin photosensitive?*
No
Yes

If yes, please descript:
Do you have any surgery on the treatment area recently?*
No
Yes

If yes, please descript:

Current Medications:


Please list all medications you have taken during last 4 weeks (if no, please notated "NONE"):

Allergies:


Please list any known allergies: (if no, please notated "NONE"): *
Skin Typing

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

Eye Color*
0. Light colours
1. Blue, gray or green
2. Hazel/Light Brown
3. Dark Brown
4. Black
Natural Hair Color*
0. Sandy red
1. Blond
2. Chestnut or dark blond
3. Brown
4. Black
Your natural skin color (unexposed area)*
0. Reddish
1. Pale
2. Beige and olive
3. Brown
4. Dark Brown
If you stay in the sun too long?*
0. Painful, redness, blistering and peeling
1. Blistering followed by peeling
2. 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
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

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 darkly 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)


Current and Future Concerns
Please indicate which of the following concerns you have regarding your skin or body?*
Aging
Acne Scar
Spider Veins
Sun Damage
Enlarge Pores
Wrinkles
Hyperpigmentation
Age Spots
Body Contouring/Fat Reduction
None
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*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Gender
Patient Gender*
Parent or Guardian's Signature*
Electronic Signature Consent*
I certified the information is true and correct. I am aware that it is my responsibility to inform the technicians of Bared Monkey Laser Spa my current medical and health conditions and to update this history is essential for the caregiver to execute the appropriate treatment procedures. I also understand 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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