Informed Consent for Laser

First Name

Last Name

Phone *

Email *

AGE: Are you under 18? *

Yes

Have you had any aspirin or blood thinners in the past week? *

Yes

Any mood altering drugs within the last 8 hours? *

Yes

Are you currently using any Retin-A, any alpha-hydroxy skin care products or topical medications or creams? *

Yes

Are you required to take antibiotics during dental or invasive medical procedures? *

Yes

Have you ever had a chemical peel, laser hair removal, laser tattoo removal? *

Yes
No

Previous problems with laser hair removal or laser tattoo removal or has your physician advised you not to have laser hair removal or laser tattoo removal treatments at this time? *

Yes

Have you had any BOTOX or fillers? *

Yes

Have you had any recent tanning or sun exposure that changed the color of your skin? *

Yes

Have you recently used any self-tanning or treatments? *

Yes

Do you form thick or raised scars from cuts or burns? *

Yes

Media Consent

I consent to any relevant photographs being taken both before and after the procedure, to document the results of the procedure strictly for internal use. *

I consent

I consent to Julie Michaud using non-personally-identifying “before & after” photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contacting Julie Michaud, which will then discontinue use of said photo(s). *

Yes

No, I do not want my photos shared.

Consent

I acknowledge, understand and agree that:

The staff with Julie Michaud does not practice medicine, does not accept health insurance, and have made no representation to the contrary; the information provided on this form is accurate and complete to the best of my knowledge, and that the staff with Julie Michaud is not responsible for complications or problems arising from any incorrect or omitted information.
Some individuals will have complications related to laser treatments. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold Julie Michaud and its employees and contractors harmless for the same.
The staff with Julie Michaud will use the information provided above to assess my suitability for the proposed laser services.
I have read the pre-procedure instructions and I will strictly adhere to post-procedure instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure.
This contract is to remain in effect for as long as I remain a client of Julie Michaud and all its contents apply whenever work is being performed on myself. It is my responsibility to inform Julie Michaud if any changes have occurred in my medical history.

By signing this form I acknowledge that I have read and understand the contents of each statement above. *

I agree

Signature for Laser Consent *

Clear