• I hereby authorize (Doctor or PA under doctor chosen above) supervision to perform light based hair reduction on me. I understand that this procedure works on the growing hairs (anagen) and not on dormant hairs. I understand that I will require several treatments to obtain a significant, long-term reduction of hair growth. I understand I may experience fewer, thinner, lighter, slower re-growth of hairs, temporary hair loss or permanent hair reduction. I understand that it is only effective on hair with color and does not treat white, grey, blond, or red hair. I understand that genetics, hormones, medication and hair color may interfere with hair loss and that I may not respond at all.

    The procedure may result in the following adverse experiences or risks:

    • DISCOMFORT/PAIN Some discomfort and/or pain may be experienced during treatment.
    • REDNESS/SWELLING/BRUISING – Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.
    • HYPOPIGMENTATION / HYPERPIGMENTATION: (Changes in skin Color): – During the healing process, there is a slight possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.
    • WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated areas.
    • SUN EXPOSURE/TANNING BEDS/ARTIFICIAL TANNING - May increase risk of side effects and adverse events.
    • If any of these occur, please call our office.
    • INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our office (949) 477-9740.
    • SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.
    • PARADOXICAL HAIR GROWTH – Stimulation of terminal hair growth following photo-epilation. Can occur within or adjacent to treated area.
    • LEUKOTRICHIA - Temporary or permanent gray hair
    • EYE EXPOSURE – Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.

    I acknowledge the following points have been discussed with me:

    • Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me
    • Alternative treatments such as electrolysis, waxing, plucking and depilatories
    • Reasonably anticipated health consequences if the procedure is not performed
    • Possible complications/risks involved with the proposed procedure and subsequent healing period

    For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Futhermore, I agree to keep (Doctor or PA under doctor chosen above) and staff informed should I become pregnant during the course of treatment.

    ACKNOWLEDGMENT

    BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR LIGHT BASED HAIR REMOVAL TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.

  • I hereby (choose one below) authorize the use of my photographs for teaching purposes.
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