Laser Hair Removal Consultation & Consent Form
Laser Hair Removal is an advanced treatment that uses concentrated light energy to reduce unwanted hair growth. Multiple sessions are required as hair grows in different cycles. Results vary depending on skin type, hair colour, hormones and individual response.
CLIENT INFORMATION
Title Mr. Mrs. Miss Ms. Other
Full Name *
Date
Address
Phone *
Email *
Date of Birth
Emergency Contact Name
Emergency Contact Number
MEDICAL HISTORY
Please list all medications you currently take (including vitamins, hormones, herbal supplements, etc.)
Do you have any allergies?
Are you currently under a doctor's care? Yes No
If yes, please explain
Are you pregnant or breastfeeding? Pregnant Breastfeeding No
Do you smoke? Yes No
If yes, how many cigarettes per day?
TREATMENT AREA
Select the areas you would like treated Upper Lip Chin Sideburns Full Face Neck Underarms Half Arms Full Arms Chest Abdomen Bikini Line Brazilian Half Legs Full Legs Back Shoulders Hands Feet Other
If Other, please specify
SKIN & HAIR INFORMATION
Skin Type Very Fair Fair Medium Olive Brown Dark Brown / Black
Hair Colour Black Dark Brown Brown Blonde Red Grey / White
Hair Thickness Fine Medium Coarse
HEALTH QUESTIONNAIRE
Please tick any condition that applies to you
Diabetes Epilepsy Cancer Heart Disease Thyroid Disorder PCOS Autoimmune Disease Lupus Vitiligo Psoriasis Eczema Keloid Scarring Herpes (Cold Sores) Skin Infection Open Wounds Recent Surgery Metal Implants Blood Clotting Disorder Hepatitis HIV/AIDS None Please provide details if applicable
MEDICATIONS
Are you currently taking any of the following?
Accutane / Roaccutane (within last 6-12 months) Antibiotics Steroids Blood Thinners Retinol / Retin-A Photosensitive Medication Hormone Therapy None PREVIOUS TREATMENTS
Laser Hair Removal IPL Waxing Threading Electrolysis Chemical Peel Microneedling None Have you waxed, threaded or plucked the treatment area within the last 4 weeks? Yes No
Have you had sun exposure or fake tan within the last 2 weeks? Yes No
Have you shaved the treatment area within the last 24 hours? Yes No
CLIENT CONSENT
I understand that:
Laser Hair Removal works by targeting hair follicles with laser energy and multiple sessions are required for optimal results. Results vary between individuals and permanent hair removal cannot be guaranteed. Possible side effects include redness, swelling, pigmentation changes, blistering, burns and, in rare cases, scarring. I have disclosed all relevant medical history and medications truthfully. I agree to follow all pre-treatment and aftercare instructions provided by Glemz Hair & Beauty Studio. I understand I must avoid sun exposure, waxing, threading and plucking before and during the course of treatment. I understand photographs may be taken for treatment records. Do you consent to photographs being used for marketing purposes? Yes No
Consent:
I understand that the final result of my LED treatment cannot be guaranteed.
I understand that after the treatment, I will be required to refrain from un-protected sun exposure.
I have read all of the above and had all my questions satisfactorily answered. In signing this informed consent, I am stating I have read the informed consent information and I fully understand the possible risks, complications and benefits that can result from the LED system.
Note:
Do not sign this form until you have read and understood all of the above.
Electronic Signature
Clear
