Laser Hair Removal Informed Consent

Please correct the errors described below.

My signature below constitutes my acknowledgment that:

2. A darkening or lightening of the skin may occur, at times up to many months following Also noted in some patients are superficial erosions, bruising, blistering, redness, and swelling. There is a rare possibility that a scar at the treatment site may develop.

3. A topical anesthetic may be applied to the skin for comfort. Protective goggles MUST be worn during the procedure. The treated area requires specific care with a mild emollient, such as an aloe containing emollient, and must be protected from sun exposure for 2-3 weeks after treatment with at least a SPF-30 sunscreen. It is important that follow-up instructions be carried out to minimize the risk of problems.

4. I understand that the treatment may involve risks of complication or injury from both known md unknown causes, and I freely assume those risks. Alternative means of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse the procedure.

5. I certify that I have read this entire informed consent and that I understand and agree to the information provided in this form. I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian/person having legal custody will also be required before This Informed Consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I agree that any pictures of my treatment site may be used for publication or teaching purposes, however, my name will not be disclosed and complete confidentiality will be maintained.

6. I understand that Koger Dermatology will uphold the standard of care that I have become accustomed to at this office. Estimated success of my treatment has been explained to me based on my skin type, hair color, and hormonal hair growth patterns.

7. No guarantee, warranty, or assurance has been made as to the treatment results.

8. I agree to adhere to all safety precautions and regulations during the laser treatment.

9. I have read and understand the information given to me regarding laser hair removal. I have had the opportunity to discuss laser hair removal with my practitioner and consent to treatment with the Light Sheer Diode Laser.

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.

Your information will be encrypted.