LASER HAIR REMOVAL CONSENT FORM
Patient name ________________________________________________________________
Treatment sites ______________________________________________________________
I hereby authorize White Pearl Medical Spa, under Dr. Altieri’s supervision to perform laser or light based hair reduction on me. I understand that this procedure works on the growing hairs (anagen) and not on dormant hairs. I understand that I will require several treatments to obtain a significant, long-term reduction of hair growth. I understand I may experience fewer, thinner, lighter, slower re-growth of hairs, temporary hair loss or permanent hair reduction. I understand that it is only effective on hair with color and may not treat white, grey, blond, or red hair. I understand that genetics, hormones, medication and hair color may interfere with hair loss and that I may not respond at all. I understand photographic documentation will be taken and used as needed by White Pearl Medical Spa.
The procedure may result in the following adverse experiences or risks:
DISCOMFORT – Some discomfort may be experienced during treatment.
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.
SKIN COLOR CHANGES – During the healing process, there is a possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.
WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our office.
INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our office 210.495.4397.
SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.
PARADOXICAL HAIR GROWTH – Stimulation of terminal hair growth following photo-epilation. Can occur within or adjacent to treated area.
I acknowledge the following pre-treatment rules have been discussed with me and I am aware of the possible complications/risks involved with the procedure and subsequent healing period:
SUN/UV EXPOSURE – Prolonged or excessive sun exposure, or tanning, within the last four weeks, including tanning beds, spray tanning, and bronzers are not allowed prior to treatment. No UV exposure for 3-5 days post treatment.
SHAVING - The area(s) to be treated must be freshly shaven prior to appointment. Shaving is required throughout the treatment plan, no waxing, tweezing, threading, hair removal creams or bleaches are to be used at all.
MEDICATION - No UV sensitive medications, including most antibiotics, for 10-14 days prior to treatment.
For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment.
ACKNOWLEDGMENT
BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR LIGHT BASED HAIR REMOVAL TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.
Patient Signature________________________________________ Date__________
Witness______________________________
