Name * First Name Last Name Email Phone * (###) ### #### Age * Medical History Have you ever had the following: Current or history of cancer, especially malignant melanoma or recurrent non melanoma skin cancer or precancerous lesions such as multiple dysplastic nevi Any active infection Diseases which may be stimulated by light, such as a history of recurrent Herpes Simplex, Systemic Lupus, Erythematosus, or Porphyria Use of photosensitive medication and/or herbs that may cause sensitivity to light exposure, such as Isotretinoin, tetracycline or St. John's Wort Immunosuppressive diseases including AIDS or HIV infection, or use of immunosuppressive medications Patient History of Horomonal or endocrine disorders such as polycystic ovary syndrome or diabetes, unless under control History of bleeding coagulopathies or use of anticoagulants History of keloid scarring Very dry skin Exposure to sun or artificial tanning during the 3-4 weeks prior to treatment Are you pregnant or nursing? * Yes No List any medications or supplements you are taking * Please list known allergies * Skin Type * When exposed to the sun without protection for about 1 hour Always burns, never tans Always burns, sometimes tans Sometimes burns, sometimes tans Hispanic Asian Mediterranean Middle Eastern Black Caucasian South East Asian/Indian When were you last exposed to the sun or tanning bed? * Are you planning a holiday in the sun in the next 4 weeks? * Artificial Tans * If you've had an artificial tan in the last 3 weeks you are not eligible for Laser Hair Removal until the tan is gone. Legit your skin will turn black if I laser over this artificial tan. Just a FYI I do not have a artificial tan Have you had botox or fillers in the last 4 weeks? * List any prior Laser Hair Removal Treatments * If you've had laser treatments before, have you had any side effects? If so please explain * Describe your hair growth or any changes you have noticed to your hair pattern * Skin Type * When exposed to the sun, select all that apply always burns, never tans always burns, sometimes tans sometimes burns, sometimes tans always tans Background * Please check all that apply African American Caucasian Asian Hispanic Mediterranean Middle Eastern South East Asian Other What areas are of concern that we are treating today? * Please select all that apply Full Face Some areas of Face Ears Neck Beard Line Up Full Arms Half Arms Underarms Full Legs Half Legs Toes & Feet Full Back Full Front (Chest & Abs) Chest Only Shoulders Abs Only Bikini Brazilian Photo & Media Consent * I give permission for my technician/therapist to take photographs and video recordings, before, during, and/or after my procedure. I give permission for my photos to be used on the company social media channels, website and used for any other marketing purpose. I further understand that there will be no financial remuneration for this. Yes No thank you Photo/Media Consent for Patient Files * I understand that my technician/therapist will be taking photographs and video recordings, before, during, and/or after my procedure for my own patient file. I agree I understand that this consent is for today's treatment and all future treatments received at Unfiltered Beauty * I understand Consent * I give consent to have a Laser Hair Removal treatment performed and assume full responsibility for the outcome. I do not and will not hold the technician, Attajaan Ramji, or Unfiltered Beauty responsible or liable should the result not be as discussed or as I had imagined. Furthermore, I understand all the risks, contraindications and potential side effects of this treatment. I agree Laser Hair Reduction Consent * Please check all boxes I duly authorize Attajaan Ramji of Unfiltered Beauty to perform the IPL/DIODE Laser Hair Removal procedure. I understand that the IPL/Laser is a device used for 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. 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 IPL/Laser 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 IPL/Laser hair removal system involves a series of treatments, and the fee structure has been fully explained to me. 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 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 understand it is recommended that I have between 6-10 treatments for optimal results and follow up with maintenance treatments as needed to maintain my results. 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. Policies * I understand Unfiltered Beauty's policies regarding late arrivals, rescheduling appointments & cancelations I understand & I agree Thank you for submitting your form, I will see you at your appointment! Laser Hair Removal Consent Form
