Cosmo Med Spa & Salon

Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation? Yes No

Do you have any of the following medical conditions? (Please check all that apply)
No Cancer Diabetes High blood pressure Herpes Arthritis Frequent cold sores HIV/AIDS Keloid scarring
Skin disease/Skin lesions Seizure disorder Hepatitis
Hormone imbalance Thyroid imbalance Blood clotting abnormalities
Any active infection

Do you have any other health problems or medical conditions? Please list:

Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced)
No
Food
Latex
Aspirin
Lidocaine
Hydrocortisone
Hydroquinone or skin bleaching agents
Others

Describe the reaction(s) you experienced:

Have you ever had laser hair removal?
Yes No

Have you used any of the following hair removal methods in the past six weeks?
Yes No

Have you had any recent tanning or sun exposure that changed the color of your skin?
Yes No

Have you recently used any self-tanning lotions or treatments?
Yes No

Do you form thick or raised scars from cuts or burns?
Yes No

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
Yes No

Are you pregnant or trying to become pregnant?
Yes No

Are you breastfeeding?
Yes No

Are you using contraception?
Yes No

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 technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

Treatment Sites:
Mono-brow
Lip
Chin
Neck
Face
Arms
Fingers
Chest
Areola
Linea
Underarms
Back
Buttocks
Bikini
Labia
Scrotum
Thighs
Lower Legs
Feet
Toes

Previous Hair Removal Methods:
Shaving
Tweezing
Waxing
Depilatories
Electrolysis
Laser

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 patients 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:

There is a risk of scarring.
I understand

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 permanent color change is a rare risk. Avoiding sun exposure before and after the treatment reduces the risk of color change.
I understand

Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
I understand

Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.
I understand

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.
I understand

I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.
I understand

Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.
I understand

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 nderstand the procedure and accept the risks. I hereby release (individual) and (facility) and (doctor) from all liabilities associated with the above indicated procedure.

Post Treatment Instructions:

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 patients that do not respond to treatments. The treated hair should exfoliate or push out approximately 2-3 weeks. Treatment duration varies from 15-120 minutes depending on the size of the area and the amount of hair.

Immediately after the treatments, there should be redness and bumps at the treatment area, which may last up to 2 hours or longer. It is normal for the treated area to feel like sunburn for a few hours. You should use a cold compress if needed. If any crusting, apply antibiotic cream. Some physicians recommend aloe vera gel or some other after sunburn treatment such as Desitin. Darker pigmented people may have more discomfort than lighter skin people and may require the aloe vera gel or an antibiotic ointment longer.
I understand

Makeup may be used after the treatment, unless there is epidermal blistering. It is recommended to use new makeup to reduce the possibility of infection. Just make sure that you have moisturizer on under your makeup. In fact, moisturizer will help the dead hair exfoliate from the follicle, so use moisturizer frequently and freely on the treated area. Any moisturizer without alpha-hydroxy acids will work.
I understand

Avoid sun exposure to reduce the chance of dark or light spots for 2 months. Use sunscreen SPF 25 or higher at all times throughout the treatment and for 1-2 months following.
I understand

Avoid picking or scratching the treated skin. DO NOT USE any other hair removal methods or products on the treated area during the course of your laser treatments, as it will prevent you from achieving your best results.
I understand

You may shower after the laser treatments, and use soap, deodorant, etc. The treated area may be washed gently with a mild soap. Skin should be patted dry and NOT rubbed. You may apply deodorant after 24 hours.
I understand

Anywhere from 5-30 days after the treatment, shedding of the hair may occur and this may appear as new hair growth. This is not new hair growth, but dead hair pushing its way out of the follicle. You can help the hair exfoliate by washing or wiping with a washcloth.
I understand

Hair re-growth occurs at different rates on different areas of the body. New hair growth will not occur for at least three weeks after treatment.
I understand

Call your physician’s office with any questions or concerns you may have after the treatment.
I understand

Please note: Stubbles, representing dead hair being shed from the hair follicle, will appear within 10-20 days from the treatment date. This is normal and will fall out quickly.

Laser Hair Removal Treatment Questionnaire

Complete form and then allow your Laser Technician to read all answers and submit.

Have you been on any antibiotics and/or sun-sensitive medications in the past two weeks? This includes any medications that are a contraindication to laser treatments.
Yes No

Have you had any long term sun exposure in the past 4 weeks?
Yes No

Are you pregnant and/or breastfeeding?
Yes No

Are you going to have any long term sun exposure in the upcoming weeks?
Yes No

Have you used any sunless tanner in the past 2 weeks on the areas that we will be treating today? It is important that you do not have any sunless tanner residue on your skin; as this can lead to pigmentation issues.
Yes No

Have you used any prescription creams on any areas of the body? Example: Retin A, Renova, Tretinoin, Avita, Alustra, Adapalene, Avage, Differin, Tazorac, Tazarotene, etc
Yes No

Have you waxed, tweezed, threaded, or used depilatories between treatments on any of the areas we will be treating today?
Yes No

Do you have makeup and/or deodorant and/or lotions on any of the areas we will be treating today?
Yes No

Do you have any of the following hair color(s) in the area(s) being treated? Gray, White, Blonde, Strawberry Blonde, Light Brown
Yes No

Do you have any tattoos on the area(s) being treated? If the answer is yes, you take full responsibility for making the Technician aware of the tattoo(s)
Yes No

I understand that I can not partake in any activities for the next 24 hours that raise my body temperature; as this can lead to pigmentation issues.
I Agree

I understand that the following Guidelines are in place for my safety and geared towards best results: Minimum of 6 weeks between treatments (4 week minimum for any area on the neck/face). As my treatments progress, it is possible that more time (up to 12 weeks) may be needed in between treatments to reach all three phases of hair growth.
I Agree

I understand that each treatment targets an average of 10-15% of my hair growth per session. It is normal to experience a growth spurt and patchiness between treatments. While very rare, with any Laser treatment there is a potential of burning and a risk of scarring.
I Agree

I understand that Laser Hair Removal is NOT an exact science and that results are not guaranteed. It is my responsibility as a patient to be honest about all changes to my medical history, as well as honesty in all questions in this form. I agree to verbalize my results from treatment to treatment; as this is how Laser Technicians gauge which settings are needed for best results. I agree to contact Cosmo Med Spa first for any concerns and/or perceived adverse reactions from my treatment(s).
I Agree

CANCELLATION/REFUND POLICY

We respect your time and appreciate your choice to spend it with Cosmo Med Spa. We've created our Cancellation Policy to provide the utmost versatility and convenience to our guests. Booking a reservation is your acceptance of our Cancellation Policy;therefore, please be certain you've reviewed and agreed to these terms.

Please respect our scheduling by keeping appointments whenever possible and providing a minimum of 24 hour notice when canceling or rescheduling appointments. Failure to comply with these guidelines will result in a loss of treatment or a fee of $25.

Less than 24-hour notification to cancel or reschedule an appointment.

No-show or missed appointments.

Late arrivals - please keep in mind that arriving late for a service may require us to shorten the length of the treatment, with fullcharges applied, so as not to inconvenience other guests. We regret that late arrivals will not receive extension of scheduled appointments unless our schedule allows.

We have a NO REFUND policy, however we will consider an exchange for other services.

Done