Electronic Medical Waiver Form Template- widely applied in the medical industry.

Welcome to Luxury Spa!

Please take your time to read and answer all questions.

Thank you!

Laser Treatment Day Consent Form

Patient Laser Treatment Day Acknowledgement

First and Last Name: * Please enter your name.

Date of Birth: *

Please enter valid date.

Treatment number * Please enter your answer here.

Skintype- Please Choose One *

Always burns, never tans

Burns easily, tans minimally

Light brown skin

Moderate brown skin

Dark brown skin

Deeply pigmented dark brown skin

Please select at least one choice above.

I HAVE / HAVE NOT waxed or tweezed within 1 month prior to laser treatment *

HAVE

HAVE NOT

Please select at least one choice above.

I HAVE / HAVE NOT taken antibiotics within 7 days prior to laser treatment *

HAVE

HAVE NOT

Please select at least one choice above.

I HAVE / HAVE NOT used self tanners/spray tans within 2 weeks prior to laser treatment *

HAVE

HAVE NOT

Please select at least one choice above.

I HAVE / HAVE NOT used any RETINOL/BENZYOL PEROXIDE containing products within 7 days prior to laser treatment *

HAVE

HAVE NOT

Please select at least one choice above.

I HAVE / HAVE NOT had sun exposure or utilized tanning beds withing 2 weeks prior to laser treatment *

HAVE

HAVE NOT

Please select at least one choice above.

I AM / AM NOT pregnant *

AM

AM NOT

Please select at least one choice above.

Patient has been advised of the following post-treatment care:

-Use sunscreen when in the sun especially on facial areas

-Do not apply lotion or moisturizer 24 hours after treatment

-Avoid saunas, hot tubs, and other situations (including exercise) that may cause heat or friction for at least 24 hours after treatment

-Do not exfoliate or use Retinol or Retin-A on any treated area for a week

-Do not tan (inside,outside or spraytan) for two weeks after treatment

-Do not use excessively hot water in bathing

-Do not pick, scratch, or rub treated area

By my my signature below, I certify that all of the above statements are true, and the treatments I receive here are voluntary and I release Apex Beauty LLC/ Luxury Spa INC and/or skin care professional from liability and assume full responsibility thereof. *

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