Celebrity Cosmetic Dermatologist

Consent Form for Laser Treatment for Hair Removal

Prime HealthAddress: 1035 Sterling Rd, Suite 104, Herndon, VA 20170

Physician Name: Dr. Han Tonthat

1. Purpose of this Consent

By signing this form, I confirm that I have been informed about the Laser treatment for hair loss, including its purpose, benefits, risks, side effects, and post-treatment care. I voluntarily consent to proceed with the procedure.

2. Description of the Procedure

Laser hair removal is a non-invasive cosmetic treatment designed to reduce and remove unwanted hair by targeting hair follicles with concentrated light energy.

How it Works:

• The laser emits specific wavelengths of light absorbed by the pigment (melanin) in the hair shaft.

• This light energy is converted into heat, which damages the follicle to inhibit or delay future hair growth.

• The procedure is non-invasive, typically lasting 15–60 minutes depending on the treatment area.

• Multiple sessions are usually required for optimal, long-term results, as hair grows in cycles.

3. Expected Benefits

The treatment aims to:

• Permanently reduce unwanted hair in the treated area.

• Provide smoother skin and decrease the need for shaving, waxing, or plucking.

• Minimize ingrown hairs and skin irritation from other hair removal methods.

I understand that results vary based on skin type, hair color, hair thickness, and adherence to a recommended treatment plan.

4.Common Side Effects (Temporary and Mild)

These side effects are typical and usually resolve within hours to a few days:

• Redness (Erythema): Mild to moderate redness in the treated area.

• Warmth or Tingling: Sensation of heat or tingling during and after treatment.

• Swelling (Edema): Temporary swelling, especially in sensitive areas.

• Itching: Mild itching due to skin healing.

• Pigment Changes: Temporary darkening or lightening of the skin. Less Common Side Effects

  These may require additional care:

  • Blistering or Crusting: Minor burns or crust formation.

  • Increased Sensitivity: Temporary discomfort when using certain skincare products.

  • Hyperpigmentation: Darkening of skin, more likely in darker skin tones.

  • Hypopigmentation: Lightening of the skin, possibly temporary or permanent. Rare but Serious Side Effects

    These are uncommon but may require medical attention:

    • Severe Burns: Due to improper laser settings or unusual skin reactions.

    • Scarring: Permanent scarring if skin healing is disrupted.

    • Infections: If skin barrier is compromised.

    • Persistent Pigmentation Changes: Long-term color changes in the skin.

5. Contraindications

I confirm that I do not have any of the following:

• Active skin infections or rashes in the treatment area.

• Recent tanning, sunburn, or use of self-tanning products.

• Pregnancy or breastfeeding.

• History of keloid or hypertrophic scarring.

• Use of photosensitizing medications (e.g., certain antibiotics, Accutane).

• Very light blonde, gray, or white hair in the treatment area (may not respond to treatment).

6. Pre-Treatment and Post-Treatment Instructions

To minimize risks and ensure proper results, I agree to follow the instructions provided by the Clinic:

Pre-Treatment:

1. Avoid direct sun exposure, tanning beds, and self-tanners for at least 2 weeks before treatment.

2. Shave the treatment area 24 hours before the session (do not wax, pluck, or use depilatory creams).

3. Avoid harsh skin treatments (e.g., chemical peels, retinoids) for 5 days prior.

4. Inform the provider of any recent changes in medication or skin health.

Post-Treatment:

1. Apply a soothing cream or aloe gel to the treated area if needed.

2. Avoid hot showers, saunas, or strenuous exercise for 24 hours.

3. Protect the treated area from sun exposure; use SPF 30 or higher.

4. Do not pick, scratch, or exfoliate the treated area for at least 48 hours.

5. Expect treated hairs to shed naturally over the next 1–3 weeks.

7. No Guarantee of Results

I understand that outcomes vary and multiple sessions are required for best results. Prime Health cannot guarantee specific outcomes.

8. Refund Policy

The Patient acknowledges and agrees to the following refund terms:

1. Non-Refundable Services: All fees for completed services are non-refundable.

2. Health-Related Refunds: If treatments are stopped due to verified health issues, refunds will be issued only for unused treatments.

3. Payment Obligations: If enrolled in a payment plan, the Patient must complete all payments, even if they discontinue the program.

9. Emergency Contact

9. Acknowledgment and Consent

By signing below, I confirm that:

1. I have read and understood this Consent Form and its contents.

2. I have been informed of the procedure, risks, and benefits, and had all my questions answered.

3. I understand the risks, including rare but serious complications, and agree to proceed with the treatment.

4. I release Prime Health, its staff, and practitioners from liability for any complications, except those caused by gross negligence or malpractice.