Fraxel Laser - Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical supervision or taking medications? *

Yes

No

If yes, please provide details:

If yes, list allergies:

Have you previouslly taken Accutane in the last 6 months? *

Yes

No

Skin Concerns and Treatment Goals

What are your goals regarding the treatment?

Have you had Fraxel or other resurfacing treatments previously? *

Yes

No

If yes, when and how was your experience?

Do you use active skincare products (e.g., AHA/BHA, Retin-A, Vitamin C)? *

Yes

No

Do you wear SPF on your daily routine ? *

Yes

No

Treatment Goals and History

Have you recently had cosmetic procedures in the past 4-6 weeks *

Yes

No

Let us know :

Have you had recent sun exposure or tanning in the previous 4 weeks? *

Yess

No

Do you have tattoos or permanent makeup in the targeted area? *

Yes

No

Are you experiencing skin irritation, infection or rash in the area to be treated *

Yes

No

Risks, Side Effects, and Acknowledgements

Please read and initial each statement for Fraxel Laser: *

I understand Fraxel laser treatment promotes skin renewal through fractional resurfacing.

I understand that a series of treatments may be needed for optimal results.

I understand that temporary side effects include redness, swelling, dryness, flaking, or discomfort.

I acknowledge that rare risks include burns, hyperpigmentation, hypopigmentation, and scarring.

I understand that proper pre- and post-care is essential to minimize risks.

I agree to avoid sun exposure and tanning before and after treatment.

I confirm I have provided accurate medical and skincare history.

I consent to clinical photographs for treatment documentation (not for public use without consent).

Client Declaration and Consent

I confirm that the information I have provided is accurate and complete.

I understand the Fraxel laser procedure, including potential risks and expected outcomes.

I have had the opportunity to ask questions, and all questions were answered to my satisfaction.

I voluntarily consent to Fraxel laser treatment at Idens Laser Clinic

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Deposit & Risk Acknowledgment Policy

Non-Refundable Deposit

I understand and agree that any deposit made for medical consultations, procedures, or treatments is non-refundable under all circumstances. This applies regardless of cancellation, rescheduling, or change of decision on my part.

Assumption of Risk

I acknowledge that all medical treatments, procedures, or interventions carry inherent risks. I have been informed of the potential benefits, risks, and alternatives related to my care, and I have had the opportunity to ask questions. I voluntarily assume full responsibility for any and all risks, outcomes, or complications that may arise from the medical care I receive. I release the provider and facility from liability for outcomes that are not guaranteed and may vary from patient to patient

Confirmation of Understanding

By signing below, I confirm that:

- I have read and fully understood this policy

- I understand the deposit is non-refundable.

- I accept and assume all risks related to my treatment.

- I sign this document voluntarily and without coercion.

Patient Name

Patient Signature:

Clear

Date: *

I agree to terms & conditions provided by the company.

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