New Patient Information

Client Information and Medical History

In order to provide you with the most appropriate skin care treatment or laser hair removal, we would appreciate your time in completing the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY

MEDICAL HISTORY

COSMETIC HISTORY

ALLERGIES

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the laser technician of my current medical or health conditions and to update this history. A current medical history is essential for the laser technician to execute appropriate treatment procedures

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Metropolitan Med Spa Informed Consent for Hair Removal

I authorize Metropolitan MedSpa to perform Laser/IPL treatments using Candela’s GentleMax

Treatment sites: mono-brow, lip, chin, neck, face, arms, fingers, chest, areola, linea, underarms, back, buttocks, bikini, labia, scrotum, thighs, lower legs, feet, and toes.

Combinations:

The purpose of this procedure is to diminish or remove unwanted hair. The procedure requires more than one treatment and may produce permanent hair removal. The total number of treatments will vary between individuals. On occasion there are clients that do not respond to treatments. The treated hair should exfoliate or push out in approximately 2-3 weeks.

Alternative methods are waxing, shaving, electrolysis, and chemical epilation.

The following problems may occur with the hair removal system.

1. There is a risk of scarring
2. Short term effects may include reddening, mild burning, temporary bruising, or blistering. Hyper-pigmentation (browning) and Hypo-pigmentation (lightening) have also been noted after treatment. These conditions usually resolve within 3-6 months, but the permanent color change is a rare risk. Avoiding sun exposure before and after the treatment reduces the risk of color change.
3. Infection: Although infection following treatment is unusual, bacterial, fungal, and viral infections can occur. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary with the help of your health care provider at your own expense.
4. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.
5. Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics, or topical preparations have been reported. Systemic reactions (which are more serious) may result from prescription medicines.
6. Avoid sun exposure: for 1-2 months following treatment. When exposed to sunlight, the use of sunscreen with SPF of 25 or above is required at all times.
7. I understand that exposure of my eyes to light could harm my vision. My eyes will be covered with laser/IPL-specific safety eyewear or an opaque material to protect them from the intense light. My eyes will be closed and I will not attempt to remove the eye protection during treatment.
8. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation. By signing below I acknowledge that I have received Laser Hair Removal Client Instructions.
9. If oxygen is used during my treatment, my provider will ensure that it is used safely. Oxygen supports combustion and may cause flash burns in the treatment area. Anesthesia is usually not necessary. My provider or I may elect to use a form of topical anesthesia to reduce any discomfort during the procedure. A cryogen spray in a cooling device may be used during the procedure to decrease discomfort and protect the skin. I accept that all anesthesia options and risks have been discussed with me in advance.
10. Metropolitan MedSpa, LLC, does not have access to physicians, medical doctor (M.D.).Also, Metropolitan MedSpa, LLC, is completely a separate entity from Gentle Dental Care.
11. You have consulted your healthcare provider before these treatments
12. If a client cancels/no shows appointment within 48 hours he or she will forfeit that treatment.

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

ACKNOWLEDGMENT

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release Metropolitan Med Spa, LLC, its officers, employees, technicians or agents from all liabilities associated with the above indicated procedure.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Metropolitan Med Spa Scale Evaluation

Please circle the answer that applies for each question:

Genetic Disposition:

Reaction to Sun Exposure

Tanning Habits

Fitzpatrick Skin Type
I
II
III
IV
V-VI

Dear Client

Please be advised should you need to reschedule an appointment do so 48 hours in advance. You will forfeit a treatment session for NO SHOWS when rescheduling with less than 48-hour notice. All purchased packages are NON-REFUNDABLE. Packages have an expiration date of 12 months from the date of purchase.

Metropolitan Med Spa communicates with clients using text messages to confirm appointments and upcoming promotions. By signing below, you are agreeing to receiving these messages.

Thank you for your understanding!

Management

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.