Laser Treatment Consent Form

Patient Information

Full Name

Date of Birth

Phone Number

Email Address

Skin Assessment

Fitzpatrick Skin Type (circle one):

Type I
Always burns

Type II
Usually burns

Type III
Sometimes burns

Type IV
Rarely burns

Type V
Very rarely burns

Type VI
Never burns

Treatment Type (tick all that apply)

Laser Hair Removal

IPL Photorejuvenation (pigmentation, redness, sun damage)

Laser Skin Resurfacing (ablative or non-ablative)

Vascular Laser (thread veins, rosacea)

Tattoo Removal

Pigmentation Treatment

Other: _______________________

Treatment Area(s)

Device / Laser Used

Settings (J/cm², pulse width)

SUN EXPOSURE WARNING

You MUST avoid sun exposure, tanning beds, and self-tan for at least 4 weeks before AND after treatment. Tanned skin significantly increases the risk of burns and pigmentation changes.

Contraindications - Please confirm you do NOT have any of the following:

Pregnancy or breastfeeding

Recent sun exposure or tan (natural or artificial) in treatment area

Active skin infection, cold sores, or open wounds

History of keloid or hypertrophic scarring

Use of photosensitising medications (e.g., Roaccutane, some antibiotics)

Epilepsy triggered by light

Skin cancer or suspicious lesions in treatment area

Gold therapy (for rheumatoid arthritis)

Pacemaker or electronic implant (check with practitioner)

Tattoos in treatment area (for hair removal)

Risks and Potential Complications

I understand that the following may occur:

Expected: Redness, warmth, mild swelling (like sunburn)

Common: Crusting and flaking (especially resurfacing treatments)

Common: Temporary darkening of treated pigmentation

Uncommon: Blistering

Uncommon: Post-inflammatory hyperpigmentation (especially darker skin types)

Uncommon: Hypopigmentation (lightening of skin)

Rare: Burns

Rare: Scarring

Rare: Eye injury (if eye protection not worn correctly)

Rare: Paradoxical hair growth (stimulation instead of removal)

Patient Acknowledgements

I have read and understood this consent form and agree to proceed with treatment.

Patient Signature

Date

Practitioner Signature

Practitioner Name (Print)