Leahswaxworks.com.au

LASER CONSENT FORM
NAME: ________________________________________________________________________________
ADD: _________________________________________________________________________________
______________________________________________________________________________________
PHONE (H):___________________________________ (M):_____________________________________
EMAIL: _______________________________________________________________________________
OCCUPATION: ________________________________________________________________________
ARE YOU PREGNANT OR TRYING TO CONCEIVE: Y/N
ETHNIC ORIGIN:_______________________________________________________________________
FITZPATRICK SKIN TYPE DESCRIPTION
(PLEASE TICK)
Type 1 -Never tans, always burns Fair Skin, Blonde Hair, Blue/Green Eyes Type 2 - Occasionally Tans, usually Burns Fair Skin, Sandy-Light Brown Hair, Green or Brown Eyes Type 3 - Often Tans, Sometimes Burns Medium Skin, Brown Hair, Brown Eyes Type 4 - Always Tans, Never Burns Olive Skin, Brown/Black Hair, Brown/Black Eyes Type 5 - Never Burns Dark Skin, Black Hair, Black Eyes Type 6 - Never Burns Black Skin, Black Hair, & Black Eyes HOW DID YOU HEAR ABOUT US?
OTHER: _____________________________________________________________ HAVE YOU HAD ANY SORT OF FACE PEEL IN THE LAST WEEK: Y/N
HAVE YOU HAD A MICRODERMABRASION IN THE LAST WEEK: Y/N
HAVE YOU HAD ANY LASER HAIR REMOVAL BEFORE:
AREA TO BE TREATED:
CURRENT METHOD OF HAIR REMOVAL? (Please circle)
Are you being treated for any medical conditions? Y/N
If so, please specify_______________________________________________________ Do you have any skin allergies? Y/N
If so, please specify_______________________________________________________ Are you on any of the following medications? (please circle)

Do you have any of the following conditions (please circle)
Polycystic Ovaries Y/N Breast Feeding Y/N Chemotherapy/Radiation Y/N Hepatitis Y/N LASER PATIENT CONSENT
The Candela Gentlelase Laser machine produces an intensive but gentle burst of light that reduces hair growth via
selective destruction of the hair follicle without harming the surrounding tissue.
Laser hair removal is successful for most clients but my results cannot be ensured or guaranteed.
An estimate of 6-10 treatments is required for a significant reduction of hair and it is extremely difficult to advise on the
exact number of treatments I may need.
Treatments must be performed within 4-8 weeks to receive the most effective treatment.
The procedure is not painless and is described as flinging of an elastic band with a bit of heat.
Be aware permanant hair reduction may not be achieved by all clients, particularly female clients with fine facial hair of
during increased time of hormonal activity e.g. menopause, puberty, pregnancy and polycystic ovarian syndrome.
Laser treament will not work on light blonde, red, white or grey hair.
No guarantee has been made with regards to dormant follicle that maybe triggered by hormonal changes, stress,
illness, pregnancy or other causes.
Facial, neck, chest hair on females is hormonal, laser does not stop hormones from producing new hair. Hair will
decrease but it is unlikely that it will disappear - numerous treatments will be needed.
Immediately following laser treatment the treated area may be red and swollen for several hours, this can be calmed
using ice and Aloe vera gel.
I have also been informed that superficial burning and pigment changes in the skin are risks and complications of this
procedure, these are usually temporary and will resolve in a few days/weeks.
This can usually be prevented by avoiding exposure to the sun, fake tan and solarium for at least 2 weeks before
and after your treatment.
Removal of make up prior to any facial laser treatment is essential as this may interfere with the treatment and may
cause burns to the skin.
Methods of hair removal whilst having laser can only be shaving or depilatory creams.
No waxing or tweezing before and after treatment, as this will reverse the effects of the laser.
I agree to wear protective eyewear to protect my eyes during treatment.
The hair must be short (2mm) and can take up to 14 days to fall out after the treatment.
NO SUN, SOLARIUM, OR FAKE TANS IS TO BE EXPOSED TO THE SKIN 2 WEEKS
BEFORE OR AFTER YOUR LASER TREATMENT.
I understand the above information and I hereby consent to the use of Candela Gentlelase laser.
Continuing Treatments Consent
I agree that nothing has changed in my medical background since my last treatment and I still understand the contents
of this page and my questions have been answered satisfactorily.
VISITS

1st:
I confirm that I have received the pre and post treatment care for laser hair removal and I agree to follow the post treatment instructions. I will inform the staff of any changes to my condition or medications with any subsequent treatments. Signature:___________________________________ Date:________________________________________

Source: http://www.leahswaxworks.com.au/download/i/mark_dl/u/4009609576/4556180661/LASER%20CONSENT%20FORM.pdf