INFORMED CONSENT LASER HAIR REMOVAL 1. Informed Consent. The purpose of this Informed Consent is to help you decide whether a laser hair removal ( LHR ) cosmetic procedure is right for you and to help you make an informed decision to undergo this procedure. This Informed Consent gives you general information about LHR cosmetic procedures, explains other treatment options, and identifies the benefits, risks, side effects and possible complications associated with LHR procedure. 2. Laser Hair Removal Procedure. LHR is a non-invasive laser treatment designed to remove unwanted hair from all parts of the body. The laser device works by emitting pulses of light energy that penetrate the skin and destroy hair follicles while the device s handpiece cools the surrounding skin. Because the laser needs to fill the hair follicle to work effectively, it is important not to wax, tweeze, have electrolysis procedures or pluck hair for 4 weeks prior to the procedure. You will be required to wear protective eye glasses during the procedure to protect your eyes from the laser light. You may feel a slight burning, stinging or pinching sensation during the procedure. Treatment of dark course hair generally achieves the best results while removal of light fine hair generally requires additional treatments which may or may not be successful. Clinical results of LHR may also vary depending on individual skin type, hormonal levels and hereditary influences. Therefore, some patients may experience partial results and some may notice no improvement at all. Future hormonal changes may cause additional hair growth. LHR procedure generally involves a series of treatments. Ideal (light skin/dark hair) candidates can usually achieve 70%-90% reduction with a series of 6 treatments. Thicker skinned areas such as men s backs, faces or neck usually require more than 6 sessions and usually achieve only partial reduction or hair thinning. 3. Alternative Procedures. LHR is a voluntary cosmetic procedure which is not necessary or required. 4. Not Good Candidates. Generally you are not a good candidate for LHR procedure if you are pregnant, nursing or plan to become pregnant while undergoing LHR treatments. Individuals who have used Accutane within the past six months or who used any medications requiring limited exposure to sunlight are not good candidates for LHR procedure. Individuals with recently tanned skin are advised to delay undergoing the LHR procedure. The laser may not be effective on blond or gray hair. Sun exposure 4 weeks prior to treatment may reduce effectiveness of the laser. It is important to shave the area prior to treatment session. (We do not
provide shaving services as you must do this yourself prior to the treatment). Please inform us if you have any medical allergies. 5. Risks and Complications. All medical and cosmetic procedures are associated with certain risks and may result in complications. Possible risks and complications associated with LHR procedure include: Temporary reddening, burning, swelling, bruising or discoloration of the skin over the treated area. Blistering, scarring, activation of cold sores, infection or permanent discoloration, which may occur in rare cases. Please inform us if you have ever had a problem with cold sores. Folliculitis, which is an infection of the hair follicle, which may take several days to resolve. Hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin), which rare may take several months to fully resolve. Crusting or blistering of the area exposed to laser, which is rare and which may take several days to heal. As with all LHR procedures, some re-growth of hair may occur after treatment sessions are completed. 6. Post Procedure Instructions. It is IMPORTANT that you follow all post-treatment instructions carefully because during the healing process, there is a slight possibility that the treated area can become either lighter (hypo-pigmentation) or darken (hyper-pigmentation) in color compared to the surrounding skin. This is usually a temporary condition; however, on a rare occasion, it can be permanent. Laser-treated area should not be exposed to sun or tanning beds. Please call your doctor promptly if complications develop after the procedure. By signing this Informed Consent, you understand and agree as follows: I have been given opportunities to ask questions about the treatment procedure(s) and all of my questions have been answered satisfactorily. I understand that no guarantees have been made to me regarding the outcome of laser hair removal and I hereby release Bared Monkey Inc. and the technicians of Bared Monkey Inc. from all liabilities associated with the above indicated procedure. I understand there are several alternative treatments to laser therapy. These include electrolysis, tweezing, waxing and shaving.
I understand that immediately following the laser treatment temporary side effects may occur, including but not limited to: redness, swelling, blistering, burns, itching, discomfort and discoloration (hyper- and hypo-pigmentation), and that scarring, while rare, is also possible. I agree to notify Bared Monkey Inc. of any of these side effects occur. I understand and agree that Bared Monkey Inc. may choose to take photos of my treatment area for the purpose of monitoring my progress. I understand that once I have started my treatment program there are no refunds. I confirm that I have received the post treatment instructions provided by Bared Monkey Inc. and I understand that it s my responsibility to follow these instructions, and that my failure to adhere to these recommendations may results in complications and contraindications for which I am fully responsible. I understand that this consent form is valid for all future laser hair removal treatments performed, and I will alert the staff if there are any changes to my medical history, or if I become pregnant. I have read the entire above Informed Consent and believe the Bared Monkey Inc. has adequately explained the risks of this therapy, alternative methods of treatment, and possible benefits form this treatment, and I hereby consent to the laser treatment to be performed by the technicians of Bared Monkey Inc. Considering that I have been informed that certain medical conditions and medications prohibit the patient from laser therapy, I have provided a full and truthful medical history and a truthful and accurate account of my medications to this office. Having been apprised of all the above, I have signed this Consent Form and authorize the subject treatment. Name Print: Signature: Date: Witness: Date: (Parent or Guardian if patient is under 18)
Laser Hair Removal Before And After Treatment Pre LHR Treatment Instruction: The area to be treated should be shaved the day before your treatment. NO Tanning (self-tanner, tanning bed, etc.) 4 weeks prior to treatment. NO plucking, waxing, using a depilatory or undergo electrolysis in the areas you wish to have treated 4 weeks prior to treatment. Shaving is the fine. NO Accutane 6 months prior to treatment. NO make-up, lotion, body oil, perfume and jewelry prior to your appointment. If you have a history of Herpes Simplex Virus or cold sores, you must pre-medicate one day prior to treatment to prevent further outbreaks. Please inform your technician of all current/changes to your medications four (4) weeks prior to your scheduled treatment. Certain medications may cause your skin to be more sensitive to both sunlight and laser light. For your safety, we need to be aware of any medications you are presently taking. Post LHR Treatment Instruction: Some redness and swelling around the treated area is normal after treatment and may feel similar to a sunburn. This should resolve within several hours to several days after treatment. Applying ice packs or cool compresses will help with any discomfort. NO exercising or working out for a minimum 12 hours until the redness has subsided. NO saunas, hot tubs, or hot showers for a minimum 12 hours until the redness has subsided. NO irritants (glycolics, acids, retinoids, etc.) for 7 days after treatment. NO real suntan or use solariums for the entire duration of course of treatments and for 1 month after the final treatment. NO plucking, waxing, using a depilatory or undergo electrolysis in between treatments. If needed, the only other acceptable hair removal method is shaving. Apply sunscreen daily. It should be at least SPF 30 protects UVA/UVB and contains the physical blockers zinc oxide and titanium oxide. It may take 1-3 weeks for the dead hairs to shed out of the follicles. It s recommended that you gently exfoliate the treated area about 7 days after your treatment, 2-3 times a week. Apply moisturizer after exfoliating to help skin replenish. If you have any questions or problems please call us at (212) 256-9777
Bared Monkey Laser Spa Laser Hair Removal and/or Laser Skin Rejuvenation Medical History and Skin Type Form Email: Date: Patient Name: Date of Birth: Address: City: State: Zip: Telephone: Emergency contact name and phone: Please specify your genetic origin: African American Asian Caucasian Hispanic Mediterranean Middle Eastern Native American Other Females: Are you pregnant? Are you breastfeeding? Are you planning pregnancy during the course of your treatments? During any past pregnancy, did you develop hyperpigmentation or masking? Do you have regular periods? All patients: Medical History--Please check all that apply AIDS Albinism Acne Bleeding disorders Botox Diabetes HIV Hirsutism Hormone Replacement Implants Kaposi s sarcoma Keloid scars Porphyria Pacemaker Permanent makeup Rosacea Seizures/Epliepsy Skin cancer Endocrine disorders Lesions/Sores/Open wounds Severe histamine reactions Epidermolysis bullosa Lupus erythematosus Skin Marks/ Molds/ Freckles Heart disease PCOS Sunburn Hemorrhoids Port-wine stain Tattoos Herpes 1&2 Precocious puberty Vitiligo High blood pressure Psoriasis/Eczema Others Gold Theraphy Are you currently being treated for any skin condition? If yes, please explain Do you have a history of bleeding coagulopathies or use of anticoagulopathies? Do you have any active skin diseases or infection in the area to be treated? If yes, please descript Do you have any skin allergies? If yes, please descript Have you had skin cancer or precancerous lesions? If yes, please descript Are there any moles with hair in the area to be treated? Are you allergic to latex, lidocaine, or any lotions? If yes, please descript Have you had any surgery in the area to be treated? If yes, please descript Have you had any prior laser treatments or other skin treatments in the area to be treated? (i.e. Cosmeceuticals/ Chemical peels/ Botox/ Laser Resurfacing etc.) Have you/are you using Accutane? Date of last use: Are you using Retin-A, Renova, Differin, or Tazorac? Date of last use: Are you using glycolic/aha home care products? Date of last use: Are you undertaking a course of treatment that may make your skin photosensitive? (See attached sheet for information and a list of common drugs) If yes, please descript Have you had exposure to sun or artificial tanning during the 3-4 weeks prior to treatment? Do you use facial depilatories (hair removal lotions)? Date of last use
Skin Typing NAME DATE Please answer the following questions by circling the number which best describes you. Your clinician will total the score during the consultation. My ethnic origin is closest to: I. Very fair (Celtic and Scandinavian) (check one) II. Fair-skinned Caucasians with light hair and light eyes III. Pale-skinned Caucasians with dark hair and dark eyes IV. Olive-skinned (Mediterranean, some Asian, some Hispanic) V. Dark-skinned (Middle Eastern, Hispanic, Asians, some Africans) VI. Very dark-skinned (African) My eye color is: Light blue 0 Blue/green 1 Green/gray/golden 2 Hazel/light brown 3 Brown 4 My natural hair color at age 18 was: The color of my skin that is not normally exposed to sun is: If I go out into the sun for an hour or so without sunscreen and have not been out in the sun for weeks, my skin will: When was the last time the area to be treated was exposed to natural sunlight, tanning booths or artificial tanning cream? Red 0 Blonde 1 Light brown 2 Dark brown 3 Black 4 Pink to reddish 0 Very pale 1 Pale with a beige tint 2 Light brown 3 Medium to dark brown 4 Dark brown-black 6 Burn, blister and peel 0 Burn, then when the burn resolves there is little or no color change 1 Burn, but then turns to tan in a few days 2 Get pink, but then turns to tan quickly 3 Just tan 4 Just gets darker 5 My skin color is so dark I can t tell 6 Longer than one month ago 0 Within the past month 1 Within the past two weeks 3 Within the past week 4 Total Score: If your score is: Your skin type is: Notes: 0 3 I 4 7 II 8 11 III 12 15 IV 16 19 V 20 24 VI
List all current Medications you are taking: Please indicate which of the following concerns you have regarding your skin? Aging Sun damage Rosacea Age spots Acne Enlarged pores Blackheads Texture Redness Wrinkles Whiteheads Other Leg veins Hair removal Oily skin Spider veins Unevenness Dry skin Scarring Hyperpigmentation Sensitive skin Please specify which areas you would like to consider for laser hair removal? Note: I certified the information is true and correct. I am aware that it is my responsibility to inform the technicians of Bared Monkey Inc. my current medical and health conditions and to update this history is essential for the caregiver to execute the appropriate treatment procedures. Signature Date