Laser Hair Removal Questionaire

Full Name *

First Name Last Name

Phone Number *

Area Code Phone Number

What areas are you interested in treating?

full face upper lip unibrow eyebrow (top & center) cheeks chin areola forehead/hairline forearms jawline ears legs (from knee down) full arms upper arm full legs legs (tights to knee) underarms bikini line feet & toes full brazilian without anal full back full beard hands & fingers full brazilian with anal happy trail shoulders full buttocks boyzilian including anal abs perianal chest lower back upper back full body

Which methods are you using now to remove hair?

tweezing waxing shaving depilatory other

When was the last time you removed the unwanted hair by this method in that area?

yesterday a week ago a month ago

How often?

everyday once a week every other week once a month

Please check one of the statements that best describes your skin at first sun exposure

always burned, never tan usually burn, tan with difficulty burn first and then tan sometime burn, tan about average rarely burn, tan with ease never burn

When was your last sun exposure? (indoor or outdoor)

one day ago one week ago a month ago

Which level of sunscreen do you use on a regular basis on the area you wish to be treated?

none SPF 15 SPF 30 SPF 50 higher

Are you currently tanned in the area(s) you wish to have treated?

Have you ever had cold sores in the area(s) to be treated?

Have you been on accutane in the past six months?

Do you take medications routinely? If yes, list all medications

list all medications

What is your ethnic background?

Consent for Laser Hair Removal

I authorize Timeless Beauty Aesthetics to perform laser hair removal on me. Treatment will be performed by trained staff.

I understand that the procedure is purely elective and the only indication is my request for treatment. I understand that insurance will not cover the procedure, nor does Timeless Beauty Aesthetics accept insurance.

For the best results, I understand that multiple treatments will be necessary and these will incur additional costs.

Serious complications are rare, but possible. Common side effects include temporary redness and mild “sunburn” like effects lasting a few hours to 3-4 days. Pigment changes lasting 1-6 months may occur in 5-20% of patients and are most likely in darker skin types and tanned skin. Other potential risks include itching, pain, bruising, burns, infection, scarring, swelling, and failure to achieve the desired hair loss. Lasers can cause eye injury and protective eyewear must be worn during treatment.

I understand that payment is my responsibility and must be paid in full prior to treatment. Packages are not transferable and cannot be broken down for use of any other body part or treatment or shared with another person. I will advise my laser technician if I have taken antibiotics or if I have been in direct sunlight within a two week time period. I am responsible for any visits beyond my six treatment package. This package cannot be refunded once purchased.

I have read the above, understand and authorize this consent. I accept the risks and complications of the procedure. I freely consent to the proposed treatment and guarantee to make payment as agreed. *

Yes

Patient Signature

Parent/Legal Guardian’s SIGNATURE Clear

Date

Month Day Year

Informed Consent Laser Hair Removal (For Minors)

I duly authorize Timeless Beauty Aesthetics to perform the Laser Hair Removal procedure and any other measures which in their opinion may be necessary. I understand that the is a device used for laser hair removal and that clinical results may vary in different skin types and hair types. I understand there is a possibility of short-term effects such as reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me.(Guardian’s Name)

Clinical results may vary depending on individual factors, including medical history, skin and hair type, patient compliance with pre/post treatment instructions, and individual response to treatment. I understand that epilation with the system is a safe alternative to methods used for removing unwanted hair, such as shaving, waxing, chemical epilation and electrolysis.

I understand that treatment by the laser hair removal system involves a series of treatments and the fee structure has been fully explained to me (Guardian’s Name)

I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

I confirm that I am not pregnant at this time, and that I have not taken Accutane within the last 6 months. I do not have a pacemaker or internal defibrillator.

I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.

Minor's Signature

SIGNATURE Clear

Minors Full Name

First Name Middle Name Last Name

Date

Month Day Year

I have read the above, understand and authorize this consent for laser hair removal treatments for minors. I accept the risks and complications of the procedure. I freely consent to the proposed treatment and guarantee to make payment as agreed.

Yes