Laser Consent Form

At Tangles Hair & Beauty Salon, we require each client to fill out a laser consent form before receiving any laser treatments at our salon. Please take a few minutes to fill out this form before your arrival, to ensure a more convenient and timely check-in.

PLEASE COMPLETE YOUR FORM HERE.

LASER CONSENT FORM

Laser Consent Form

Date *

Month *

Day *

Year *

First Name *

Last Name *

Phone Number *

Email Address *

Date of Birth *

Month *

Day *

Year *

Chosen Laser Treatment *

I consent to receive the GentleMax Pro Laser Treatment selected above, and I acknowledge that the Laser Treatment will be performed by a trained and certified Tangles Hair & Beauty Salon Technician. *

I Consent

Please Initial Below *

I understand that the GentleMax Pro is a device used for hair removal, skin rejuvenation, wrinkle reduction, pigmented lesions, leg veins and other vascular lesion treatments, of which I am consenting to be a patient *

I Understand

I understand that clinical results may vary depending on individual factors including but not limited to medical history, skin type, client compliance with pre and post treatment instructions, and individual response to treatment. *

I Understand

I acknowledge that during the laser treatment, my eyes will be covered with laser-specific safety eyewear, or an opaque material to protect them from the intense light. I agree that I will not attempt to remove the eye protection during the treatment until permission is given to me by the Technician. *

I Acknowledge & I Agree

I understand that there is a possibility of short-term effects such as reddening, itching, swelling, mild burning, herpes simplex virus activation, scabbing, crusting, temporary bruising and temporary discolouration of the skin, as well as the possibility of rare side effects such as burns, blisters, scarring and permanent discolouration. *

I Understand

Please Initial Below *

I agree that these effects have been fully explained to me, and I understand that complete clearing may not be possible and will depend upon the type, age and colour of the lesion. *

I agree & I Understand

I understand that treatment with the GentleMax Pro often involves a series of treatments and the fee structure has been fully explained to me . *

I Understand

Please Initial Below *

I understand that the Technician may use a cryogen spray or skin cooling device during the procedure, to decrease discomfort and protect the skin. I understand that the Technician or I, may elect to use a form of topical anesthesia to reduce any discomfort during the procedure. *

I Understand

I understand that immediately following the laser treatment, that redness, swelling, discomfort, bruising, and discolouration may develop at the treatment site. I also understand that any discolouration may last 7-14 days, and swelling should resolve within several days. I understand that discomfort may be treated with the application of cool compresses or topical soothing agents. *

I Understand

I understand that I will be given complete instructions regarding after care of the treated area. I also understand the importance of following the after care instructions carefully to minimize the chance of incomplete healing, skin textural changes or scarring. I agree to avoid prolonged, direct exposure to the sun during my healing time,. I also understand that tanning should be avoided. *

I Understand

I acknowledge and agree to the following statements: * I have provided my past and current medical history and medications. I consent to the taking of photographs during the course of my laser therapy for my healthcare records. I consent to the use of my photographs for medical education and/or marketing purposes. I understand that my name will not be used to identify my photographs. I am NOT pregnant. I have been given the opportunity to ask questions about the procedure. *

YesNo

If you answered No, to any of the above statements, please submit your questions here.

My questions have been answered and I understand the information given to me. *

YesNo

If you answered No, to the above statement, please voice your concerns here.

All contraindications (a specific situation in which a procedure or treatment should not be performed because it may be harmful to the client) to the performance of this procedure have been discussed in detail with me. *

YesNo

If you answered No, to the above statement, please voice your concerns here.

I recognize that the practice of medicine is not an exact science and acknowledge that no guarantees have been made to me concerning the results of such procedures. *

Yes

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 have read and understood all information presented to me before signing the digital Signature on this consent form. *

I Agree

Signature *