Laser Consent Form There was an error trying to submit your form. Please try again. Client Name * This field is required. Date * This field is required. Date of Birth * This field is required. Contact Number * This field is required. Email * This field is required. Section A: Treatment Area Please indicate the areas you wish to treat * Face Underarms Arms Legs Bikini Back Chest This field is required. Section B: Medical History: Do you have any of the following conditions? Are you taking any medications (e.g., antibiotics, Accutane, blood thinners)? * Yes No This field is required. Are you currently pregnant or breastfeeding? * Select an option Yes No This field is required. Diabetes: * Select an option Yes No This field is required. Epilepsy * Select an option Yes No This field is required. Skin disorders (eczema, psoriasis, vitiligo) * Select an option Yes No This field is required. If yes, please name your disorder: This field is required. Hormonal disorders (PCOS, thyroid issues): * Select an option Yes No This field is required. If yes, please name your disorder: This field is required. Keloid scarring * Select an option Yes No This field is required. Cancer (current or past) Select an option Yes No Section C: Select the answer that best describes your natural skin. Eye Color * Select an option Light blue/green Blue/gray Hazel Dark brown Brown-black This field is required. Hair Color * Select an option Red/light blonde Blonde Light brown Dark brown Black This field is required. Natural Skin Tone * Select an option Porcelain Fair Olive/light brown Medium brown Deep brown This field is required. Freckles * Select an option Many Several Few Very few None This field is required. Sun Reaction * Select an option Always burns Usually burns Mild burn Rarely burns Rarely burns This field is required. Ability to Tan * Select an option Never tans Slight tan Moderate tan Easy tan Deep tan This field is required. Sun Sensitivity * Select an option Very sensitive Sensitive Slightly sensitive Resistant Very resistant This field is required. Face Reaction to Sun * Select an option Peels/burns Often burns Sometimes burns Rarely burns Never burns This field is required. Consent & Signature I confirm that the information I have provided in this consultation form is accurate and complete to the best of my knowledge. I understand that withholding or misrepresenting information about my medical history, medications, lifestyle, or skin type may increase the risk of adverse reactions during or after treatment. I acknowledge that laser hair removal is a cosmetic procedure designed to reduce hair growth and that results may vary depending on individual factors such as hair color, thickness, skin type, and hormonal influences. * This field is required. I have been informed of the nature of the treatment, including the expected benefits, limitations, and potential risks such as redness, swelling, blistering, pigmentation changes, scarring, or infection. I understand that multiple sessions are required to achieve optimal results and that maintenance treatments may be necessary. I also recognize that laser hair removal does not guarantee permanent hair removal but rather long-term hair reduction. * This field is required. I agree to follow all pre-treatment and post-treatment instructions provided to me, including avoiding sun exposure, tanning, and using recommended skincare products. I understand that failure to follow these instructions may increase the likelihood of complications. * This field is required. I consent to photographs being taken of the treatment area for medical documentation and progress tracking, with the assurance that these will remain confidential. By signing below, I release the practitioner and clinic from liability for any unforeseen reactions or outcomes, provided that all standard protocols have been followed. I understand that I may withdraw my consent at any time, but doing so may affect the outcome of my treatment plan. * This field is required. Submit There was an error trying to submit your form. Please try again.
