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Consent and Liability Form for Repeat Laser Treatment
Name
(Required)
First
Last
Email
(Required)
Treatment Date
(Required)
MM slash DD slash YYYY
Areas Being Treated
(Required)
List any medications you are currently taking or have taken within the last two weeks:
(Required)
List any new medical conditions or skin conditions diagnosed since your last treatment:
(Required)
Have you had any of the following since your last visit? (check all that apply)
(Required)
Extended sun exposure, used self-tanning cream or any permanent makeup or fillers in the past 8 weeks;
History of herpes in the site to be treated or have you had a chemical peel in the past two weeks?
Used Accutane within the last 6 months?
None of these apply to me
Explain all or any new prescription skin products used in the last two weeks:
(Required)
Have you had any changes in the appearance of your skin from any of the previously treated areas from laser hair removal?
(Required)
Yes
No
If yes, please explain:
Are you pregnant or breastfeeding?
(Required)
Yes
No
Acknowledgement
I hereby renew my consent for another treatment for laser services, and I agree to abide by all aftercare instructions. I understand the procedure and accept the risks. I hereby release
Bonnie Kelly, Berkshire Hair Removal
from all liabilities associated with the above indicated procedure.
When you select the button below, you will be taken to a screen to sign this document electronically. If you are unfamiliar with electronic signatures, please
watch this short video.
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