IPL laser hair removal

Patient name:
Treatment sites:
The laser/IPL is a device that produces an intense but gentle burst of light.
For hair, this light destroys hair follicles while the device’s handpiece cools the surrounding skin. Because the laser needs to fill the hair follicle to work effectively, it is important not to wax, tweeze, have electrolysis procedures, or pluck hair for 2-4 weeks prior to the procedure.

For lesions, this light is absorbed by and causes selective heating of certain cells in the unwanted lesion. Lesions will usually fade over time as these destroyed cells are eliminated by normal body processes. My eyes will be covered with laser/IPL -specific safety eyewear to protect them from the intense light. My eyes will be closed and I will not attempt to remove the eye protection during treatment.
I duly authorize UEMSPA to perform Laser/IPL treatments using the following machines:
  • Vbeam
  • Smoothbeam
  • Gentlelase
  • GentleYag
  • GentleMax
  • AlexTriVantage
  • Smooth Peel
  • Ellipse 12PL
  • Soprano Ice
I am aware of the following possible risks and side effects of this procedure:
  • Purpura (red-purple discoloration, bruising)
  • Itching (hive-like response which lasts 2-3 hours to 2-3 days).  
  • Herpes simplex virus activation
  • Burns, blisters, scabbing, crusting, skin color and/or textural changes
  • Hyperpigmentation (darkening of the skin, transient or long term)
  • Hypopigmentation (lightening of the skin, transient, long term, or possibly permanent
  • Scarring (rare, possibly permanent)
  • Folliculitis, which is an infection of the hair follicle, it may take several days These to resolve.
  • Possible adverse effects have been fully explained to me.
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 skin cooling device may be used during the procedure to decrease discomfort and protect the skin. All anesthesia options and risk will be discussed with me in advance.
I understand that immediately following the laser treatment, redness, swelling, discomfort, bruising, and discoloration may develop at the treatment site. I further understand that any discoloration may last 7-14 days, and swelling should resolve within several days. Discomfort may be treated with the application of cool compresses or topical soothing agents.
For hair removal: I understand that clinical results of Laser Hair Removal may vary depending on individual skin type, hormonal levels, and hereditary influences. Some patients may experience partial results and some may notice no improvement at all. Treatment of dark, coarse hair generally achieves the best results while light, fine hair generally requires additional treatments which may or may not be successful.
For lesions: I understand that complete clearing may not be possible and will depend upon the type, age, and color of the lesion. Multiple treatments may be needed for the best results. Also, other methods of treating this condition have been discussed with me such that I may asses the risks and benefits of these alternative methods.
I have provided my past and current medical history and medications.
I am not pregnant.
I have had the opportunity to ask questions about the procedure. My questions have been answered, and I understand the information given to me.
Contraindications to the performance of this procedure have been discussed in detail with me.
I understand that although complications are very rare, sometimes an unexpected outcome may occur and that prompt treatment is necessary. In the event of any unexpected outcome, I will immediately contact the esthetician /technician who performed the treatment.
I have disclosed to the treatment practitioner all information that has been requested and agree to have this treatment performed on me.
I agree to have my photo taken before the treatment and I understand that I may be asked to return for a second photo after my skin has healed.
I acknowledge that I have read and received a Post Op Care Sheet and further agree to follow all post procedure care instructions as I am directed.
I release management and staff of ‘UEMSPA’ from any and all liability associated with any injuries and or current or future conditions resulting from the skin care procedures or products.
I consent to the use of my before, during and after photographs for education, promotion or advertising purposes with / without the exclusion of showing my full-face identity.
I have read and understood all information presented to me by UEMSPA before signing this consent form.