Berkshire Hair Removal

Consent and Liability Form for Repeat Laser Treatment


Consent and Liability Form for Repeat Laser Treatment

Client Name:

Email:

Treatment Date:

Areas Being Treated:

List any medications you are currently taking or have taken within the last two weeks:

List any new medical conditions or skin conditions diagnosed since your last treatment:

Have you had any of the following since your last visit:

  • 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 2 weeks;
  • Used Accutane within the last 6 months;

Answer:

Explain all or any new prescription skin products used in the last two weeks?

Have you had any changes in the appearance of your skin from any of the previously treated areas from laser hair removal?

If yes, please explain:

Are you pregnant or breastfeeding?

ACKNOWLEDGEMENT

 

Leave this empty:

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Signed by Bonnie Kelly
Signed On: July 5, 2023


Signature Certificate
Document name: Consent and Liability Form for Repeat Laser Treatment
lock iconUnique Document ID: 5177b9ad14eaf5c34bc073ee77cfe053b296f2d8
Timestamp Audit
June 13, 2023 9:01 pm EDTConsent and Liability Form for Repeat Laser Treatment Uploaded by Bonnie Kelly - bonnie@berkshirehairremoval.com IP 35.149.231.136