Laser Hair Removal Consultation & Consent

1. Client Details

Full Name *

Date of Birth *

Age

Gender *

Address *

Mobile *

Email *

Emergency Contact Name *

Emergency Contact Number *

2. Medical History

Select all that apply. Select None if no condition applies.

Medical Details *

3. Medications

Are you taking any medication? *

YesNo

Have you taken roaccutane with in the last 12 months? *

YesNo

Medication Details *

Are you taking any medication that light sensitivity? *

YesNo

4. Skin & Hair Assessment

Fitzpatrick Skin Type *

Natural Hair Colour *

Hair Thickness *

Recent Sun Exposure? *

Spray Tan Within 2 Weeks? *

5. Previous Hair Removal

Select at least one.

Date of Last Hair Removal *

6. Treatment Areas

Select at least one.

7. Contraindications

Select all that apply. Select None if not applicable.

Contraindication Details *

8. Patch Test

Patch Test Completed? *

Patch Test Date

9. Informed Consent

I have answered all questions honestly and completely.
Laser hair removal reduces hair growth but does not guarantee permanent removal.
Multiple sessions may be required and results vary.
Possible side effects include redness, swelling, discomfort, blistering, burns, pigmentation changes and rarely scarring.
Hormonal or medical conditions may affect results.
I will follow pre-treatment and aftercare advice.
Treatment may be postponed or refused if unsafe.
Clinical photographs may be taken for confidential records.
I may withdraw consent before treatment.

I have read, understood and agree to all informed-consent statements above. *

10. Aftercare Confirmation

Use SPF 30 or higher.
Avoid hot baths and saunas for 24–48 hours.
Avoid gym or strenuous exercise for 24 hours.
No waxing or plucking between sessions; shave only.
Avoid fake tan before treatment.
Report unusual reactions immediately.

I have received, understood and will follow the aftercare advice. *

11. Data Protection & Marketing

I consent to the clinic using my personal and medical information for treatment and clinical-record purposes. *

Marketing is optional.

EmailSMSPhoneNo Marketing

12. Client Declaration

I confirm the information provided is true and complete. *

Client Signature / Full Name *

Date *

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