Aeris Medical Laser Hair Reduction Treatment

I authorize Aeris Medical Aesthetics, and / or a designated practitioner of Aeris Medical Aesthetics, to perform hair reduction with Laser or BBL on the following area(s) of my body:*

Laser and / or BBL (BroadBand Light) therapy targets hair follicles for the purpose of selectively destroying them while leaving the surrounding tissue (skin) intact. The purpose of this procedure is to diminish or remove unwanted hair.

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Facts about light therapy

Hair reduction requires more than one treatment and does not remove all hair. Generally hair reduction is decreased in the amount of hair growth by 60-90% on average. Results depend on color and location of hair follicles. A general range of 4-12 treatments spaced 4-8 weeks apart is possible for maximum results.

Light from a laser can be harmful to eyes and wearing special safety eyewear is necessary at all times during the procedures. Light from BBL is an intense burst of light and even though the special safety eyewear is in place, you will sense light emanating from the treatment area. The sensation of light may be uncomfortable in certain areas and feel like pin pricks or bursts of heat. The use of topical anesthetics is at the discretion of the practitioner as there are known severe allergic reactions to ingredients in topical anesthetics. Patient’s with known allergies to anesthetics please list them below.

Common side effects and risks

Redness and irritation
Crusting or Scabbing
Changes in skin color
Eye injury
Risk of skin infection
Burns and blisters (uncommon)
Scars (uncommon)

Do you have any allergies to anesthetics*

YesNo

If yes, please list below

I have read and understand the first and second section: *

Alternative methods of hair reduction are: shaving, waxing, electrolysis, chemical epilation, and threading. I choose hair reduction therapy by laser and/or BBL light therapy.

I understand that compliance with pre and post care instructions is crucial for success of hair reduction therapy and to prevent unnecessary side effects or complications.

I understand that the hair reduction therapy involves payment and the fee structure has been explained to me.

If you have any questions or concerns please call our office at 505-433-4043

In case of emergency contact your provider.

Amanda Medina- Amanda@aerismedical.info

Lawrence Armijo-Lawrence@aerismedical.info

I do or do not consent to photographs and other audio-visual and graphic materials before, during, and after the course of my therapy to be used for medical, marketing, and education purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.*

I DoI Do Not

Patient Name*

First NameLast Name

Patient Signature*

Date*

Date

I understand that although good results are expected, there cannot be any guarantee or warranty, expressed or implied, that I will be completely satisfied by the outcome or that I will not require additional treatment and/or ongoing treatment to achieve the result I seek. I understand that treatments will not cure any medical conditions nor provide immunity against re-occurrence of such conditions. The treatments are temporary and vary per patient with some patients experiencing shorter or longer effects. The number of treatments needed varies per patient and may be affected by the following factors including but not limited to: degree of skin irregularity; severity of volume loss; patient age; personal medical profile; basic metabolic rate; previous cosmetic procedures; history of trauma to the treated area; individual lifestyle choices; and individual patient preference.I understand that all product and service sales are final. No refunds on services or products. I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement.I understand and voluntarily accept the risks associated with all the services provided at Aeris Medical Aesthetics, including but not limited to: Waxing, Facials, Tanning, Injections, Laser Services and skincare products, etc., or the use of any of the location’s facilities. Except where prohibited by law, I acknowledge and voluntarily assume the risk of injury, accident or death which may arise from the use of any skincare products or services performed by Aeris Medical Aesthetics. I agree Aeris Medical Aesthetics will not be liable for death or any injury, including, without limitation, personal, bodily or mental injury, economic loss or damage to me resulting from negligence, other acts of Aeris Medical Aesthetics, anyone acting on Aeris Medical Aesthetics’ behalf, or anyone using the services or facilities of Aeris Medical Aesthetics, to the fullest extent permitted by law.This agreement, together with Aeris Medical Aesthetics’ post-care plan rules and regulations, constitutes the entire agreement between you and us and cannot be amended, except in writing by both parties. Myself and/or any of my heirs, executors, representatives, or assignees hereby release Aeris Medical Aesthetics from all claims or liabilities for death, personal injury or property loss or damages of any kind sustained while on the premises. I agree that this form and waiver is in effect for all services offered by Aeris Medical Aesthetics, and will not expire unless specifically requested by either party.I understand that Aeris Medical Aesthetics is a tranquil and professional environment and that any inappropriate behavior may result in termination of my services and full payment is expected. I also understand that any medical device used by the patient outside of Aeris Medical Aesthetics’ care or failing to list or mention such medical devices could result in unexpected or unwanted results.By signing this form, I agree to the above terms and release Aeris Medical Aesthetics and its employees from any liability.*

I understand & I Agree

Staff or Medical Director Signature