Please Complete The Following Consent Form
The purpose of this consent form is to provide written information regarding the risks, benefits and alternatives of Laser Hair Removal. This material serves as a supplement to the discussion you have with your Bloom Health provider. It’s important that you fully understand this material, so please read this information thoroughly. If you have any questions regarding the treatment, ask your Bloom Health provider prior to submitting this consent form.
TREATMENT GOALS AND DESCRIPTION OF PROCEDURE
Laser Hair Removal is a safe and effective method for reducing unwanted hair in various body areas, such as the legs, arms, face, chest, back, bikini area, and more. Laser Hair Removal works by directing high intensity light at hair follicles just under the surface of the skin. Light energy is absorbed by the bulb of the hair follicle and converted to heat, inhibiting future hair growth. Hair growth occurs in three phases: anagen (growth), catagen (transitional), and telogen (resting) phases. Laser Hair Removal only targets hair in the anagen growth phase, so you'll need multiple treatments to catch all the hairs during this phase. Laser Hair Removal also depends on your skin color and hair color. Depending on the amount of melanin in your skin in relation to melanin in the hair follicle, different energy settings are needed to ensure safety and effectiveness.
During your treatment session, you'll be placed in a comfortable position, the treatment area will be identified, the skin will be cleaned and shaved, and a protective gel may be applied. Protective eyeware is provided. Your laser technician will safely deliver treatment in the planned treatment areas, moving the laser handpiece across the skin. During treatment, you may experience some mild warming or burning sensation of the skin, but overall, treatment is usually tolerated without significant difficulty. Following the procedure, a skin peeling effect is normal, and the skin may feel tight, dry, or sensitive to touch for a number of days. For some patients, especially darker skin types, we may advise a specific pre- and post treatment skincare regimen, in order to calm melanocytes and avoid post-treatment hyperpigmentation.
Most patients are pleased with the results of their Laser Hair treatment. However, like any aesthetic treatment, there is no guarantee that you will be completely satisfied. There is no guarantee that your hair will disappear completely, or that you will not require additional treatment to achieve the results you seek. Multiple treatments are needed to achieve a full effect, with a usual recommendation of 6 treatments, spaced a number of weeks apart. Additional treatments may be required periodically, as touch up. The results of treatment are dependent on many factors including but not limited to: age, sex, tissue conditions, areas treated, your general health and lifestyle conditions, and sun exposure.
Following your Laser Hair Removal treatment, we’ll provide you with verbal and/or written aftercare instructions. These include, but may not be limited to the following: 1) Resume your usual bathing, moisturizing and skin routine following treatment; 2) Avoid direct sun exposure in the treated areas for at least 2 weeks or longer, especially if you plan to receive follow up laser hair treatments; 2) Apply any prescribed post-treatment topicals as directed 3) Plan your next laser hair removal session for 4-8 weeks out; 4) If you received laser hair removal on the face, okay to resume active skincare products such as hydroquinone or tretinoin after 72 hours; 5) Avoid vigorous exercise, sauna, jacuzzi or swimming for 72 hours; 6) Abstain from any additional laser treatments, microdermabrasion or microneedling in the treated areas for at least 2 weeks, or more; 7) If at any time you suspect you’re having an unexpected side effect, adverse reaction or complication, contact us immediately, and obtain help in an appropriate medical setting (i.e., Bloom Health, your primary care provider, specialist, urgent care, or acute care facility). I will adhere to the aftercare instructions supplied to me during my visit.
POTENTIAL RISKS AND COMPLICATIONS
Before undergoing Laser Hair Removal, understanding the risks is essential. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy. There are certain inherent and potential risks and side effects in any dermatologic procedure, and in this specific instance such risks include but are not limited to: 1) Temporary redness and mild sunburn-like effect; 2) Flaking or dryness of the skin, and in rare cases scab formation; 3) Scarring; 4) Rarely, post treatment bacterial, and/or fungal infection requiring further treatment; 5) Post-inflammatory hyperpigmentation which can occur infrequently, and may resolve or remain permanent, and may require further treatment and follow-up; 6) Post treatment discomfort/swelling.
PREGNANCY AND CONTRAINDICATED CONDITIONS
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have active herpes, active cold sores, psoriasis, warts, raised moles, sunburn, or active skin infection in the areas to be treated. I have not taken Accutane in the past 12 months. I have not had electrolysis, waxing, or microneedling in the last 2 weeks.
I understand that Laser Hair Removal is an elective treatment with goal of improved aesthetic appearance and that the main alternative to therapy is to observe and not receive any treatment. Other available therapies might include hair trimming, electrolysis, or waxing.
I understand that Laser Hair Removal is not covered by insurance, and payment is my responsibility and is expected at the time of treatment.
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue my Laser Hair Removal treatment at any time.
RELEASE OF LIABILITY
I hereby indemnify Bloom Health, PLLC from any liability relating to the treatments that I have volunteered for. I understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-treatment questions or concerns to the treating clinician. Furthermore, I hereby indemnify the facility/meeting room/hotel where this treatment is being performed from any liability relating to the procedures that I have volunteered for.
CONSENT TO TREATMENT
By entering my initials below, I hereby voluntarily consent to Laser Hair Removal for the purpose of reducing unwanted hair in the desired treatment areas, as performed by my Bloom Health provider and assistant technicians. I have read the above and understand it. I state that I read and write in English. I am not under the influence of drugs or alcohol. The treatment has been fully explained to me and my questions have been answered satisfactorily. I accept the risks and complications of this elective treatment and I understand that no guarantees are implied as to the outcome of the treatment. Please note this consent is valid for all future Laser Hair treatments I choose to receive from Bloom Health.