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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:

Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Signed by Bonnie Kelly
Signed On: July 5, 2023

Timestamp

Audit

June 13, 2023 9:01 pm EDT

Consent and Liability Form for Repeat Laser Treatment Uploaded by Bonnie Kelly - bonnie@berkshirehairremoval.com IP 35.149.231.136