Laser Hair Removal INFORMED CONSENT FORM Print (click here)
Iris Beauty Solution appreciates your patronage and interest in Laser hair removal. Please read and fill out this Disclosure and Release form completely, making certain that the address and telephone numbers are correct. Name:_______________________________________________________________________________________ Address/Province/City/Postal Code:_____________________________________________________________ Email:____________________________________Age: _______ Phone #:_______________________________ Voucher number(s)__________________________Barcode(s)________________________________________
You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. This disclosure is not meant to frighten you. It is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure.
CLIENT DISCLOSURE Please read the statements below, putting your initials before each one, to indicate:
I understand the following completely:
______The goal of laser hair removal is the gradual, permanent reduction of hair in unwanted areas. Every individual is unique which makes it difficult to guarantee the specific number of treatments needed. Results vary with the individual depending on skin color, hair color, hair density, hormones and medications. It is expected that I will require on average 8 to 12 treatments and possibly more. Touch up treatments will be needed in the future.
_______Hair that is white, blond or red may not respond to laser hair removal.
_______Laser hair removal is not recommended for tanned patients until the tan has faded. If tanned skin is treated the outcome may not be as successful as on not tanned skin. Sun exposure must be avoided between treatments and for 6 weeks before or after treatments. This includes sun exposure and tanning beds. Artificial tanning products must be discontinued 2 weeks prior to treatments. Test patch treatments may be done to evaluate skin responsiveness.
_______Eye damage may occur if protective eyewear provided is not worn.
_______Loss of pigmented lesions such as freckles and moles may occur if in the treatment area.
_______Expected side effects such as discomfort, redness and swelling can occur and usually subside in 1 to 3 days. Rarely, bruising, blistering, and/or infection can occur and usually requires 1 to 3 weeks to heal. Scarring may occur after blistering. Pigment changes such as hypo-pigmentation (lightening) or hyper-pigmentation (darkening) are very rare and usually resolve in 3 to 6 months but can be permanent. There may be risks not yet known at this time.
________A small percent of people do not respond to laser/light therapy. This may not be determined until after a few treatments.
________There may be an increased occurrence of side effects if I do not follow the aftercare instructions.
________Laser hair removal treatments are not recommended under certain medical situations such as heart disease, diabetes, cancer, history of keloid scarring, pregnancy, breastfeeding or active infection such as cold sores or genital sores. If I am on photosensitizing medication such as Accutane, hair removal is contra-indicated. None of these conditions apply to me or if they do I realize I am at increased risk of side effects or complications. I will inform the technician if my medical condition changes over the course of treatment.
_______ Appointment booking, cancellations or changes have to be done though online service only at www.irisbeautysolutions.ca. Accounts have to be registered with Full Slate for easy operation.
________ A written 48 hour cancellation notice is required or your session will be voided without a refund. Late arrivals can also void a session without a refund. Signed Consent Form has to be brought on the first appointment or early arrival is need to read and sign it in the office.
________Free consultation for laser treatments with Patch test should be booked separately at least 24 hours prior treatment.(For dark skin up to 48 hours).
________According to Classification of Items for disinfection of the Personal Services Establishment Regulation, laser head which touches client’s skin cannot be soaked and has to be wet wiped with an intermediate level disinfectant and air dried after each client. Iris Beauty Solution uses High level of medical grade disinfectant to clean surface of the IPL head after each client to kill all viruses and bacteria. Disposable cotton pads for eye-ware, paper towels and sheets are provided for each client. Protective goggles and clipper’s blades are reusable and sanitized by disinfectant and 70% - 90% isopropyl alcohol.
________ All services are subject to GST. Gratuity’s recommended minimum is 15% calculated on amount paid for service or voucher.
________During the two weeks before the IPL Laser Hair Removal procedure you should avoid pulling out your hair, or removing it with cream or wax. Shave hair on the area a day before, hair should not be longer than 2 mm, Shaving can be provided at the location for $25 fee and additional time should be booked.
________For your increased comfort and safety we offer disposable Cold Ice pack application prior to laser treatment .This option greatly reduces discomfort on sensitive areas such as underarms and bikini area and increases results of the treatment. During period treatment on bikini and Brazilian provided subject to the presence of the tampon.
________ Laser hair removal appointments have to be booked 8 weeks apart. In any case where this schedule cannot be followed, I acknowledge that a 1 year unlimited laser hair removal deal has a maximum value of 6 visits per 12 month period. (Please see the fine print of the voucher).
________We accept external deal site vouchers for New clients only. If you are an existing client and have bought a discount voucher through a deal site such as Social Shopper, Groupon, or any other provider, we will NOT accept it so please refund it immediately. IMPORTANT: If you are an existing client, we will consider, at our sole discretion, matching a valid and active discount voucher price, which has not expired, for any such service advertised by our company through an external deal site, provided that you purchase the discounted service through us directly.
_________For each referred guest, you will receive a credit of $10 (service must be bought directly from us). You can use the credit earned for any service at our clinic. This offer cannot be combined with any other promotion including Grupons and other vouchers.
_________Due to limited space only clients arrived for service are allowed in the waiting room.
_________I acknowledge that any information contributed by me is true, to the best of my knowledge and that the the present condition of the area that has been treated or will be treated is stated on this record. I fully understand that Iris Beauty Solution only provides beauty services; there is no medical treatment involved. _________I realize that with any beauty service there may be certain risks which must be understood. I will be fully responsible for any and all results which may arise from these beauty services. I do hereby agree to free V. Kuzmin, I Kouzmina and 0582551 BC Ltd DBA Iris Beauty Solution , their employees and agents, from any and all claims or suits for damage, for injuries or complications resulting from any beauty service provided by Iris Beauty Solution.
_________The nature and purpose of the beauty services, the risks involved and the possibility of complications have been fully explained to me. I understand that no guarantee or assurance has been given by anyone as to the results that may be obtained. By signing below I acknowledge that I have read and understand the above and all of my questions have been answered and that I consent to have the above beauty service.
Signature:_________________________Date : ____________________________________
AFTER CARE INSTRUCTIONS
1.If treated area is red and irritated 3 -5 hours after Laser Hair Removal session: No hot bath, no sweat, no sun (use sunscreen on a daily basis with an SPF of 30 or higher), no swimming pools. Use tepid to cool water and be gentle with the skin. Apply Aloe Vera gel or moisturizing cream to the skin in the morning and evening day after treatment.
2. In case of blistering Do not open or pop blisters. Opening the blisters will make the area more vulnerable to infection. Apply a topical hydrocortisone cream and/or antibiotic cream to the burn and watch the skin for sighs of infection.
3.You need to strictly avoid the sun for 4-6 weeks before and 4-6 weeks after each session to avoid pigmentary changes. 4.Avoid waxing, plucking or threading laser hair removal methods on treated areas for at least 48 hours afterward. Shaving, however, continues to be allowed between treatments.
Signature:__________________________Date : ____________________________________