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.
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.
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