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Laser to You

Lytchett House

13 Freeland Park

Wareham Road

Poole, Dorset

BH16 6FA

07311 272362

lasertoyou@aol.com

Laser Hair Removal Consultation Form

If you are underage for this treatment this clinic cannot proceed with the service without the consent of a parent or guardian.

If you have any medical conditions or are on any medication, you should check with your doctor before having the laser treatment.

Date of Birth

MEDICAL HISTORY

Are you receiving treatment from a doctor, hospital or specialist?
No
If Yes, please provide details.
Are you or have you been taking any medication prescribed by your doctor in the last 6 months?
No
If Yes, please provide details.
Are you taking any herbal remedies, e.g: St. Johns Wort?
Yes
No
Have you had any major surgery in the last 3 months?
No
If Yes, please provide details.
Is there any possibility of pregnancy?
Yes
No
Do you suffer from acute or chronic skin disease? E.g Acne
No
If Yes, please provide details.
Have you used self-tanning products or sun beds recently?
Yes
No
Please choose if you have any of the following conditions:
Do you suffer from allergies?
No
If Yes, please list below.
How often do you use Acne Medication/ Topical Cream?
Regularly
Recently
Never
Have you used Roaccutane?
No
If Yes, when did you stop the treatment?
How often do you use Antibiotics?
Regularly
Recently
Never
How often do you use Oral/Topical Steroids?
Regularly
Recently
Never
Do you have any natural or false tan on or near the areas being treated?
Yes
No
Do you have any tattoos/ semi-permanent make-up on or near the area being treated?
No
If yes, please list all areas where there is a tattoos/ semi-permanent make-up.
What body area are you considering for laser hair removal?
What have you previously used to remove your unwanted hair?
Shaving
Waxing
Other
If you had waxing done, how long ago?
What colour is your hair in the area you want to be treated?
What is your Hair Thickness?
Fine
Medium
Coarse
Could you please select the skin phototype/ tone in the area you'd like to have treated?

I have read, agree to and understand the following points:


I hereby authorise and direct Laser to You to perform laser hair removal treatments on me.

  1. Test spots may be done to evaluate skin response prior to full treatment. A patch test may be required to continue treatment if more than 6 months have lapsed.

  2. I am aware that laser hair removal only treats dark hairs and understand that blonde, grey, white and red hairs will not be removed in my treatments.

  3. I understand that the hair MUST be removed by shaving only 24 hours prior to my laser treatment as the treatment cannot be carried out otherwise. I understand no waxing, plucking, bleaching or depilatory creams are to be used while treatment is ongoing.

  4. Multiple treatments are needed, a course of 6-8 treatments are initially needed, but some people require more. Hair loss may be permanently reduced after several treatments, but not in all cases. Top up treatments will be needed in the future. Results vary with the individual depending on skin colour, hair colour, hair density, hormonal fluctuations and certain medications. I understand that for maximum results, it is necessary to follow the recommended treatment schedule. I also understand some people do not respond to treatments. I am aware that my progress will be assessed and discussed at every appointment, if needed I will be prescribed a maintenance course from your laser practitioner.

  5. Laser therapy is not recommended if any of the following conditions exist: Pregnant or Nursing Female, Photosensitivity disorder, Immuno-suppressive disease, Diabetes, Bleeding Disorder, Seizure disorder triggered by light, active Herpes, active Shingles or any active infection. I have notified my practitioner if I have one or more of the conditions above.

  6. I agree to inform Laser to You if any changes in medication or health occur as this may affect my treatment and results.

  7. I understand that treatment is not recommended for tanned skin and treatment will cease until the tan has faded and sun exposure must be avoided between treatments. I have not tanned, and will not tan, in the areas to be treated during the entire treatment course and for six weeks before and after treatment. This includes sun exposure and tanning booths. Artificial tanning products must be discontinued two weeks prior to treatments.

  8. Photographs of the treatment may be taken for my chart and future comparison. Complete confidentiality will be maintained.

  9. Loss of pigmentation lesions such as freckles/ moles may occur.


  10. Pre/ Post treatment instructions – a copy of these instructions are available to me on Laser to You website as well as on my email. I accept responsibility in complying with the treatment care instructions provided, before and after each of my laser hair removal treatments.


  11. The most likely possible complications/ risks involved with the proposed procedure include, but are not limited to: infections, skin grazing, re-growth of hair and/ or blistering.

  12. Blistering/ Bruising/ Redness/ Swelling/ Red square marks. Short term effects may include reddening, swelling, and mild heat generation which typically lasts 1-7 days. Bruising, blistering, crusting or flaking rarely occur but require 4-12 weeks to fully heal.


  13. I agree to inform Laser to You of any tattoos that I have or get in the future. I am aware of the following possible risks/ complications with laser treatments.


  14. Discomfort. Some mild discomfort may be experienced during laser treatments. Most people describe the treatment as uncomfortable more than painful. Our laser machine has a cooling tip, making the treatment more comfortable.


  1. Infection. Skin infection is possibility although rare, whenever a skin procedure is performed. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with and without a past history of herpes simplex virus infections. Antiviral medication is recommended and is available by prescription. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary. Folliculitis can also be another rare reaction.

  2. Scarring. However slight, there is a risk of scarring and skin textural changes. It is important that you follow post treatment instructions carefully. Compliance if crucial for healing and prevention of scarring.

  3. Pigment changes. Hyper pigmentation (darkening) and hypo pigmentation (lightening) of the skin have been noted after treatment. These conditions usually resolve within 3-6 months, but permanent colour change is a risk. Avoiding sun exposure before and after the treatment reduces the risk of colour change. It is very important not to be tanned (even minimally) when treated. Depigmentation of the hair is very rare. Very rarely an increase in hair growth can occur.


  1. Eye exposure. Protective eye wear will be provided. It is important to keep these goggles on at all times during the treatment in order to protect your eyes from accidental laser exposure.


  1. The treatment cost has been discussed with me and I agree to this. I understand the procedure and accept the risks which have been outlined. I certify that I have read the above informed consent and fully understand it. I have been given ample opportunity for discussion with the therapist and all my questions have been answered to my satisfaction. I consent to the terms of this agreement.


  1. Discretion of Our Practitioner: We care about your results, and our skilled practitioner will make the best decisions based on your progress. They’ll provide any additional sessions if Hair-free Guarantee applies and will guide you throughout the process to ensure you’re getting the results you deserve. We'll offer up to 4 additional sessions at no extra cost (Terms & Conditions apply) https://www.lasertoyou.com/terms-conditions

Acknowledgment: At Laser to You we strive to provide our clients with the best possible service and results. We understand that circumstances may arise that require changes to your treatment plan.


Gift Vouchers/Packages are non-refundable other than within the 14 day cancellation period if you have not started using this Gift Voucher/Package.


Package refunds: Value packs or courses of treatment are only refundable for medical reasons.


If you have any questions or concerns regarding our refund policy, please don't hesitate to contact us. We're here to assist you in any way we can.


Laser hair removal expiry date: All treatments from a course must be taken within 24 months of the date of purchase; any treatments left unused after 24 months will be automatically redeemed and a new package will need to be purchased.


Cancellation Policy: Our cancellation policy is in place to ensure that we are able to maximise our appointment availability for all our clients. This ensures that we are able to offer a cancelled appointment time to a client who needs it.

Should you need to cancel or reschedule, we kindly ask that you call us at least 48 hours before your appointment. Our phone number is 07311 272 362. Any cancellation within 48 hours will result in your pre-paid treatment being forfeited.

I confirm that I have read, agree and understand the above points.
Yes
No

PRIVACY POLICY

The following privacy notice outlines how Laser to You collects, uses, protects your personal data.

https://www.lasertoyou.com/privacy-policy


TERMS & CONDITIONS

https://www.lasertoyou.com/terms-conditions

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