Laser Hair Removal – 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: *

Are you currently taking any medications? ( List names of the ones who apply): *

Antibiotics
Hormones
Accutane
Retinoids
Blood thinners
Steroids

Have you had recent cosmetic treatments in the area targeted? *

Yes

No

Have you had laser hair removal before? *

Yes

No

If yes, please let us know details: *

Do you have any tattoos or permanent makeup near the area to be treated? *

Yes

No

Do you have any tattoos or permanent makeup near the area to be treated?

Let us know : *

Skin Type (Fitzpatrick I-VI): *

Recent sun exposure/tanning in the last 4 weeks? *

Yes

No

If yes, date of last exposure *

Risks, Side Effects, and Acknowledgements

Please read and initial each statement regarding the Laser Hair Removal: *

I understand laser targets hair follicles and results vary.

I acknowledge multiple treatments are required.

I understand side effects can include redness, pigmentation change, etc.

I will notify the clinic of any adverse reactions.

I agree to pre/post care instructions.

I confirm no Accutane use in last 6 months.

I consent to before/after photos for documentation.

Client Declaration and Consent

I confirm I have read and understood the information provided.

I have had the opportunity to ask questions.

All questions were answered to my satisfaction.

I consent to laser hair removal 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

Date: *

I agree to terms & conditions provided by the company.

Privacy Policy | Imprint

Privacy Policy Imprint Our Services

Designed by Metanow

Laser Hair Removal – Comprehensive Consent and Concern Form

Do you have any tattoos or permanent makeup near the area to be treated?

Risks, Side Effects, and Acknowledgements

Client Declaration and Consent

Idens Laser Clinic Aesthetics © All rights reserved