IPL/ Laser Hair removal Consent Form Date(Required) DD slash MM slash YYYY First Name(Required) First Last Name(Required) First Date of Birth(Required) DD slash MM slash YYYY Phone(Required)Email(Required) Your Address(Required) Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Occupation How did you hear about us?(Required)Internet searchGift VoucherLetter BoxReferredWalk byGumtreeCudo/DealsYellow PagesGrouponOtherWould you like to be informed of our specials?(Required)(Please ensure you have clearly supplied your email id & contact no. above) Yes No Please tick(Required) I confirm that I am over 18 years old (or have Parent/Guardian consent) I consent to have IPL/Laser Hair Reduction treatment through 1st Lady Health & Beauty I understand that I will need to have multiple treatments to achieve and obtain optimal results I am aware that results cannot be guaranteed. I have advised my technician of all of my current medications I have also advised of all of the treatments and products that I have used on the treatment area in the past 7 days I agree to wear protective eye shields during the treatment I understand, The purpose of this treatment is to reduce or eliminate unwanted hair. I understand that the results from this treatment vary with each individual. I understand, I should follow Post-Treatment care(Required) Keep hydrated Apply an ice pack to the area to reduce heat and possible swelling Avoid all heat treatments including hot baths, saunas, steam baths, and hot showers Avoid exercise and swimming Avoid exfoliation in that area Avoid perfumed products e.g., soaps, creams, or perfumes. Do not use bleaching creams. Do not touch, pick scratch, or otherwise irritate the treated area. No shaving next 72 hours Avoid waxing, plucking, threading (at all times during a course) Limit sun exposure and do not use tanning beds. Apply a broad spectrum sunscreen to the area (if the area is exposed to the sun) Please tick(Required) I understand that failure to follow the above instructions could lead to potential complications from this I have been discussed and read after care information for IPL/Laser hair removal. I understand that the following are risks and potential complications from this treatment:(Required) Erythema (redness) lasting up to 72 hours Hyperpigmentation (darker patches of pigment) on the skin which has the potential to be permanent however a skin lightening cream can be used to lighten this, Hypopigmentation (lighter patches of pigment) on the skin which has the potential to be permanent. Infection leading to a scar if I do not care for the area correctly. Please tick(Required) The treatment benefits and risks involved have been explained to me. I have had all my questions answered and freely consent to the treatment. Are you currently under a doctor’s care?(Required) Yes Doctors Name: ___________________________ No Doctor’s Phone: __________________________ What areas are you wanting to have treated with IPL/Laser hair removal?(Required)Are you currently on any medication? Some medications may affect your result outcome.Please list ALL medicine taken in the last week Medical Information: (Please tick any that apply)(Required) Epilepsy Diabetes Hormone condition or therapy Keloid scarring Oral contraceptive Pregnant or planning to become pregnant Cancer/melanoma Pacemaker Genital Herpes None of above Previous chemical peels, microdermabrasion, resurfacing treatments, muscle relaxants, derma fillers in the treatment area?(Required) Yes, When: ___________________________ No Have you applied fake tan in the area to be treated in the past two weeks?(Required) Yes No Do you have tattoos or permanent makeup in the area to be treated?(Required) Yes No Have you had significant sun exposure in the last two weeks?(Required) Yes No Have you waxed, tweezed or used depilatory creams in the area?(Required) Yes, how recently?: ___________________________ No consentInitial(Required) I am satisfied with the information obtained from this procedure I have been informed that results may vary to everyone. and I have been explained aftercare instructions. 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