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Informed Consent for Hair Removal pg 1 of 2

By Charlie Hunter,2014-05-16 17:21
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Informed Consent for Hair Removal pg 1 of 2

    Informed Consent for Hair Removal

Customer’s name:____________________________ Date:______________

Treatment sites: mono-brow, lip, chin, neck, face, arms, fingers, chest, areola, linea,

    underarms, back, buttocks, bikini, labia, scrotum, thighs, lower legs, feet, and toes.

    Combinations:__________________________________________________

Previous hair removal methods______________________(shaving, tweezing, waxing,

    depilatories, electrolysis, laser, ect.)

The purpose of this procedure is to diminish or remove unwanted hair. The procedure

    requires more than one treatment and may produce permanent hair removal. The total

    number of treatments will vary between individuals. On occasion there are patients that

    do not respond to treatments. The treated hair should exfoliate or push out in

    approximately 2-3 weeks.

Alternative methods are waxing, shaving, electrolysis, and chemical epilation.

The following problems may occur with the hair removal system:

    1. However slight, there is a risk of scarring.

    2. Short term effect may include reddening, mild burning, temporary bruising or

    blistering. Hyper-pigmentation (browning) and Hypo-pigmentation (lightening)

    have also been noted after treatment. These conditions usually resolve within 3-6

    months, but permanent color change is a rare risk. Avoiding sun exposure before

    and after the treatment reduces the risk of color change.

    3. Infection: Although infection following treatment is unusual, bacterial, fungal,

    and viral infections can occur. Herpes simplex virus around the mouth can occur

    following treatment. This applies to both individual with a past history of herpes

    simplex virus and individual with no known history of herpes simplex virus

    infections in the mouth area. Should any type of skin infections occur additional

    treatments or medical antibiotics may be necessary.

    4. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures.

    Should bleeding occur, additional treatment may be necessary.

    5. Allergic reaction: In rare cases, local allergies to tape, preservatives used in

    cosmetics or topical preparations have been reported. Systemic reaction (which

    are more serious) may result from prescription medicines.

    6. I understand that exposure of my eyes to light could harm my vision. I must keep

    the eye protection goggles on at all times.

    7. compliance with the aftercare guidelines is crucial for healing, prevention of

    scarring, and hyper-pigmentation.

Occasionally, unforeseen mechanical problems may occur and your appointment will

    need to be rescheduled. We will make every effort to notify you prior to your arrival to

    the office. Please be understanding if we cause you any inconvenience.

Acknowledgment:

    My questions regarding this procedure have been answered satisfactorily. I understand the procedure and accept the risk and the terms of this agreement. I hereby release Ting Long, Parker Laser and Anti-Ageing Clinic, LLC/ Parker Day Spa, Heather Hayes, Kelly Thompson and Dr. Timothy Judd from Liability associated with this procedure. This release is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns.

_______________________________ ______________

    Client Signature Date

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