Self Assessment
Choose Consent Form
lasemd consent form english
File Number:
LaseMD Consent Form
Terms and Conditions:
• Possible Side Effects: mild redness or warmth and sloughing of the skin may occur in the first few hours after treatment
• During treatment you feel some heat and tingling as the laser passes over the skin
• Avoid using cosmetics containing alcohol for at least one week after treatment, and cosmetics which contain active ingredients such as Retinol or AHA after treatment without prior permission from the doctor.
• Client experiences may vary.
• Avoid excessive sun exposure and use a SPF sunscreen.
• Any contraindications will void this offer and treatment
• This treatment cannot be transferred to another person
• Once the machine has been turned on, refunds are prohibited
• Appointments preferences are based on machines availability
I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:
• Pre and post treatment instructions have been explained to me
• Have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction
• Must notify the clinician if my medical history changes prior to subsequent treatments
• I consent to clinical photographs being taken of my treated areas for my personal health record only
• My signature below constitutes my acknowledgment and understanding of all this information
Patient Name
Patient Signature
Date /Time
Parent or Guardian (if patient is minor)
Witness
Patient Signature
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