Laser Hair Removal Consent Form Name* Type Full Namehereby authorize Dr. George Kamajian or any delegated, qualified, staff member to perform: Name of procedureI understand that the Laser Hair Removal procedure will require several treatments to obtain a significant, long-term reduction of hair growth. I also understand some people may not experience complete hair loss even with multiple treatments and that it is only effective on hair with color and does not treat white, grey, blonde, or red hair. I understand that genetics, hormones, and hair color may interfere with hair loss thus, favorable results for everyone are not guaranteed and I am undergoing treatments at my own risk. By signing below, I acknowledge and understand that the following topics have been discussed with me prior to any procedure being performed: Possible alternative procedures such as electrolysis, waxing, plucking and depilatories Potential benefits of the proposed procedure Probability of success Reasonably anticipated consequences if the procedure is not performed, if any Possible Post-Procedure Experiences and Risks and subsequent healing period Post-treatment instructions Pregnancy status By signing below, I hereby indicate that I am not pregnant.Photographs I authorize the use of my photographs for marketing purposesBY SIGNING BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE INFORMATION REGARDING THE PROCEDURE I WISH TO BE PERFORMED AND AFTER CAREFUL CONSIDERATION, I WISH TO PROCEED AT MY OWN RISK. I HEREBY AUTHORIZE DR. GEORGE KAMAJIAN AND OR HIS DESIGNATED STAFF TO PROCEED AS OF THE EFFECTIVE DATE NOTED BELOW WITH ANY AND ALL PROCEDURES AS NECESSARY AND UNTIL TREATMENT IS CEASED AND OR COMPLETED.Type Patient Name* Type Staff Name* Effective Date* MM slash DD slash YYYY DateDr. K’s Laser Hair Removal Guarantee Our goal is to meet or exceed every client’s expectation. The success of laser hair removal is based on genetics, hormones, following a treatment protocol, and laser technology being utilized during your procedure. Cynosure Vectus produces permanent hair reduction and is safe for all skin types. Treatments are performed every 6 to 8 weeks. Most of our clients are very satisfied after six treatments. Packages include 6 treatments and 4 free treatments. Packages must be paid in full at the time of purchase. There are no refunds once treatment has started. If you completed all six laser treatments in accordance with protocols and time cycles of the package you purchased, then after 8 weeks following the sixth treatment has been completed, you will receive 4 free treatments to be redeemed within 12 months. Transferring the complimentary 4 touchups to other areas is not permitted. Purchase of a laser hair removal package entitles clients to our lifetime appearance promise. Future laser hair removal treatments in the originally purchased area will be performed at 75% off the non-discounted per treatment price. By initialing below, I acknowledge the policy explained above.Appointments and Scheduling A specific appointment is reserved for your treatment. Please arrive for your appointment on time. If you are more than 15 minutes late for an appointment, we will not be able to treat you, unless the schedule permits. Rescheduling without a 24 hour notice or missing an appointment will all result in a $25 office fee. Your late fee must be paid before your treatment. We schedule our appointments in advance, preferably to ensure you stay on track with your hair growth cycle and achieve maximum effectiveness. We request a 24 hour advanced notice of any cancellations for all appointments. Please leave a message on our answering service if our receptionist is not available. Due to safety regulations, children are not permitted in the laser treatment room area. We advise that they be supervised in the reception area. By initialing below, I acknowledge the policy explained above.Melasma Melasma generally occurs when your hormones go astray. It’s a natural darkening of the skin caused by excessive production of melanin (the pigment that causes your skin to tan). These melanin cells exist at various depths in the skin making treatment difficult. Melasma will worsen when exposed to the sun. It can affect pregnant women, women taking birth control pills or hormone therapy and even some men who are genetically predisposed to this lifelong hyper pigmentation issue. Treatment: There are no guarantees of treatment results with any Melasma therapy. All treatment plans include the understanding that more than one treatment is usually necessary to achieve the desired cosmetic result, and that Melasma may worsen with treatment regimens. Options include: Lasers are one of the safest options for treating Melasma. The IPL is ideal for removing dark pigmentation. For best results, you will need more than one treatment. Microdermabrasion is a cosmetic technique that uses a mechanical medium for exfoliation to remove the outermost layer of dead skin cells from the epidermis. Bleaching Agents typically use 4% Hydroquinone and 0.1% Tretinoin. Often combination therapy works when single treatments do not. Possible Post-Procedure Experiences and or Risks Depending on the procedure being performed, you may experience some of the following: 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. PIGMENT CHANGES (Skin Color) – During the healing process, there is a possibility that the treated area can 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 at (727) 518-1000. 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 immediately at (727) 518-1000 for instructions. SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the changes of scarring, it is IMPORTANT that you follow all post-treatment instructions carefully. EYE EXPOSURE – Protective eyewear (shields) will be provided. It is important to keep these shields on at all times during the treatment in order to protect your eyes from injury.Pre Treatment Instructions Please arrive 15 minutes prior to scheduled appointment for paperwork. Please shave the area you wish to be treated the same day or night before your appointment, unless advised differently. Once the decision has been made to begin laser hair removal treatments, you are no longer allowed to tweeze, wax, or use any other depilatories between treatments. We will not be able to treat you if you have an active cold sore. It is advised that you pre-medicate one day prior to treatment to prevent any possible breakouts. It is required that you do not take antibiotics 3 days prior to and 3 days post treatment. If you are on an antibiotic regimen, please call us at least 24 hours in advance to reschedule. Avoid sun exposure, tanning beds, and tanning creams at least 3 weeks prior treatment, or we will not treat you. Instead, use at least an SPF 30 sunscreen. Acne patients having used Accutane should have discontinued the use of it for at least 6 months prior to laser hair removal. Avoid using irritating products like Retin-A, exfoliants, glycolic acids, astringents, alcohol, etc. for at least 7 days before treatment. On the day of treatment, do not use creams or deodorant on the area to be treated. Wear loose, comfortable clothing that will not rub the treatment area. Please inform our staff before treatment if you have a history of hyper/hypo-pigmentation or inflammation, scarring, or have sensitive skin. Post Treatment Instructions Avoid sun exposure for 1 week after your treatment and for at least 3 weeks before your next appointment. The treated area may be pink or appear speckled for a few days. Some of the treated hairs will fall out in about 10-30 days. Each follicle pushes itself out from the bottom up and may at first appear to be growing. Avoid using irritating products like Retin-A, exfoliants, glycolic acids, astringents, alcohol, etc. for at least 7 days after treatment. Apply cold compress to area if it feels hot after your treatment. Aloe Vera 1% Hydrocortisone applied for any irritation can be effective. If blistering occurs, apply antibiotic ointment such a Bacitracin and cover with a nonstick bandage until the wound is healed. Do not rupture or pick at the blisters since it may cause scarring. It is common to not see much reduction in hair growth until after about the 3rd treatment. Untitled* I acknowledge that I have read the consent form and understand it.I have been adequately informed with the risks and benefits of this treatment . By ticking the box, I agree to proceed with the procedure. Staff signature ___________________ Patient signature ___________________ CAPTCHA
