Laser Hair Removal | Rammy Rose

Laser Hair Removal: Online Consent Form

Please fill out the following form.

First name

Last name

Phone

Address

Email

Date of birth

Year

Month

Day

Age

Please check all current and prevoius medical conditions listed below that apply to you

Are you being treated for any other conditions not listed above?

Yes

No

Are you currently using Retinol Cream or Accutane

Yes

No

Are you using any products that contain AHA's or Glycolic Acids?

Yes

No

Have you had any piercing or tattoos?

Yes

No

Have you had any botox or fillers in the last 3 months?

Yes

No

Have you had any tanning service within the last 3 months?

Yes

No

Have you had any severe sun burns within the last year?

Yes

No

Please check the box after understanding each statement below

The goal of laser hair removal is improvement. When using laser hair removal procedures, the number of treatments depends on several factors including but not limited to skin color, tan, hair color and hormonal levels. The laser can cause a reduction in hair or cause profound hair growth delays, but results vary from person to person.

In order to achieve better results and limit complications, we require that you shave a day before your appointment. I understand that if the area is not shaved a day before and would like to get a stronger treatment right after shaving. Rammy Rose Hair and Beauty Ltd. and any of their staff would not be liable for any complications.

The laser hair removal poses an acceptably low risk of side effects or complications. However, the following side effects or complications may occur or are theoretically possible with laser hair removal:

Discomfort on treatment sites with transient redness and possibly some swelling

Pigment change, decrease or increase in pigmentation typically lasting for weeks; especially in darkskin

Inflammation of the hair follicle, known as folliculitis

Blistering, crusting, scabbing, especially in sensitive areas like bikini line and neck

Redness after treatment could be up to 48 hours

Searing is a very, very low probability as a side effect but it might happen in very sensitive skin types or in certain conditions

The treatment fees have been discussed with me and I understand them. We require 24 hours notice if cancellations or 50% treatment cost will be charged

THIS AGREEMENT AFFECTS YOUR LEGAL RIGHTS. READ IT CAREFULLY

I have been informed of the proper use of equipment for the services I am receiving
I have been advised of all risks associated with the use of equipment required for the services I am receiving. I have been advised of all the risks associated with the services and procedures I will be recieving. I agree to comply with all instructions provided by the operator.
I have given an accurate account of the questions asked above including all known allergies or prescription drugs to products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I have read and understood the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. If I have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my esthetician immediately
I hereby release Rammy Rose Hair and Beauty Ltd. its affiliates, officers, directors, agents, employees and contractors from liability for any injury, loss or damage that may result from my use of equipment or from any services provided or treatment rendered. This release binds my heirs, successors and assigns

Name

Date

Signature

I declare that the info I’ve provided is accurate and complete.

Please show your filled form to the service provider, without their acknowledgement, this form cannot be submitted, and we will not start the service until the form is submitted

Service Provider Signature

I have checked the client’s form for any contraindications and have consulted with the client what the effects of these contraindications will have during and after the service