Consent Form Laser Hair Removal

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Laser hair removal uses focused light to target hair follicles, reducing hair growth in the treatment area over time. The number of treatments needed varies by individual based on hair type, skin tone, and area being treated. Please review the contraindications and health questions below to determine if laser hair removal is appropriate for you.

Have you had hair laser removal before?

Yes

Please list when and which areas

Please list, in order of priority, all areas you would like to be treated (e.g. bikini, underarms, lower leg, back etc:

Have you used any of the following hair removal methods in the past 5 weeks?

Do you have any tatoos?

Yes

Please list where

Health Information

Are you currently taking any medications (prescription, over-the-counter, or supplements)?

Yes

Please list:

Do you have any allergies (e.g., to topical products, medications)?

Yes

Please specify:

Have you had recent sun exposure, tanning, or used self-tanning products (past 2 /4 weeks)?

Yes

Please specify dates:

Do you have a history of skin cancer or any other serious skin conditions?

Yes

Please specify dates:

Do you have a history of hormonal imbalances, such as PCOS, that may affect hair growth?

Yes

Please specify dates:

Have you had any recent cosmetic treatments (e.g., chemical peels, microdermabrasion) in the treatment area?

Yes

Please specify:

Do you have a history of livedo reticularis, an autoimmune disease, in which the blood vessels are constricted, or narrowed resulting in mottled discoloration on large areas of the leg or arms?

Yes

Please specify:

Do you have a history of erythema ab igne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irradiation?

Yes

Please specify:

Have you ever used Accutane (Roacutan)?

Yes

Please specify when was the last time:

Do you have any scar tissue?

Yes

Please specify:

Please read and check each statement to confirm your understanding and agreement.

I understand that laser hair removal may cause temporary discomfort, redness, swelling, or pigment changes in the treated area.

I confirm that I have disclosed all relevant health information, including medications, allergies, and recent cosmetic treatments.

I acknowledge that multiple sessions are typically required for optimal results and that the number of sessions needed varies by individual.

I understand that results vary based on skin type, hair type, and adherence to post- treatment care.

I agree to follow all pre-treatment and post-treatment care instructions provided by [Clinic/Provider Name].

I consent to the use of photographs of the treated area(s) for documentation and monitoring purposes. (Photos will remain confidential unless otherwise agreed upon.)

By signing below, I confirm that I have read, understood, and agreed to the terms outlined in this consent form. I am aware of the potential risks, benefits, and side effects of laser hair removal, and I consent to proceed with the treatment.

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Consent Form Laser Hair Removal

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