Laser consent form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number *

Area CodePhone Number

Birth Date

MonthDayYear

Where did you hear about us? *

Which treatment are you interested in?*

Have you used any of the following in the past 30 days?*

When was your last holiday?

Date

When is your next holiday

Date

Please select any of the following that apply to you*

Please specify any medication conditions that are not listed above *

List any medication you are currently taking *

Have you ever used or currently using retin A or Glycolic Acid?*

Have you ever used or are you currently using Roaccutane? *

If yes when did you last use Roaccutane

Date

What products are you currently using on your skin (including body)?*

If you have implants please specify the area

Have you had any major surgery performed in the last 3 months?*

Do you have any skin sensitivities or allergies?

If yes when?

Date

Are you currently taking any of the following? *

If you are currently on any of the above medication you will need to provide a drs note to confirm you are ok to have the treatment.

I hereby authorise skinbar Ltd to treat me using the AW3® system. I understand that the reduction/ removal may not be 100%. I also understand that the treatment using the AW3® system may need to be performed in repeated sessions in the future to obtain optimal results. I have been informed about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have. I understand that there are certain risks associated with the treatment and they include but are not limited to the following: Post-treatment discomfort like localised swelling, redness and mild tenderness.• Although uncommon the treatment may cause blisters or light burns to the surface of the skin. (Light /Laser Treatment Only)• Transient hypo or hyper pigmentation may occur and will normally fade in 3 to 6 months.• Crust formation “dirty skin” look is commonly seen for up to 10 days after treatment. (Light /Laser Treatment Only)• Scabbing, Swelling, and bleeding can occur but these are temporary. (Light /Laser Treatment Only)Below are a list of treatment(s) that will apply to me when accepting this consent.1) Hair Removal: Intense Pulsed Light / Laser treatment is a method of treating unwanted hair. Unwanted hair may be caused by medical conditions such as hirsuitism, hypertrichosis and other disorders. Treatments using the AW3® System will not cure any medical conditions causing unwanted hair. The purpose of the treatment is to achieve cosmetic improvements by reducing hair growth by using Intense Pulsed Light /Laser to destroy hair follicles.2) Thread veins /Pigmented lesions- Using the AW3® Intense Pulsed Light / Laser system is a method of treating vascular and pigmented lesions. The purpose of the treatment is to achieve cosmetic improvements using Intense Pulsed Light/ Laser to destroy vascular and/or pigmented lesions.3) Skin Rejuvenation/ Acne Treatment- Intense Pulsed Light /Laser treatment is a method of treating sun-damaged skin. Over exposure to UV light can cause mottled/uneven pigmentation, open pores, sunspots and damaged blood vessels. Treatments using the AW3® system will not cure any medical conditions causing pigmentation or thread veins. The purpose of the treatment is to achieve improvements in the appearance of the skin by improving skin colour, tone and pore size using Intense Pulsed Light /Laser to target excess pigmentation and thread veins.4) Wrinkle Reduction- Intense Pulsed Light / Laser treatment is a method of treating superficial fine lines and wrinkles. Everyday aggressors and skin ageing are some conditions that influence the skins collagen network and appearance. Treatments using the AW3® system will not cure any medical conditions causing fine lines and wrinkles.The purpose of the treatment is to achieve improvements in the appearance of the skin by improving collagen production within the dermis so therefore aiding in the skin turgor, texture and pore size using Intense Pulsed Light/ Laser. Accepting Terms and Consent* I agree to follow the post treatment recommendations advised by operator/company above in order to ensure the best possible results. For Light/ Laser Treatments, I understand that excessive heat should be avoided for 48 hours and that exposure to the sun, including sun beds, must be avoided for 30 days before treatment and 30 days after treatment. (AW3 Super IPL and AW3 Super Laser may vary and your specialist can advise) A sun block of SPF 30+ must be used on the exposed skin areas, otherwise it might be possible that blotchy skin pigmentation, hyper- or hypo-pigmentation might occur.I agree to co-operate with the recommendations of the company or the personnel while I am under their care, realising that any lack of co-operation could result in less than optimum results. I agree to inform the above operator/company immediately if any adverse effects occur. I agree to photographic documentation of the treated area prior to treatment. I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure. I agree to pay for the above mentioned services and understand that there will be no refunds for any performed services. This consent form and cost covers above selected treatments only. Additional treatments can be added to this consent form and will be charged for as per clinic price list, including single shot treatments. I have been made aware of the risks and I accept these terms and conditions as part of my treatment. We accept no liability for any of the above side effects. By accepting this, I agree to the terms and conditions and in the event of any of the above. I or any of my representative will not pursue the above person / company in any means of compensation. *

Print name date

Signature*

Laser consent form

Medical information

Informed Concent