SOPRANO LASER CONSENT FORM

Patients Full Name: _________________________________ Date of Birth: __________________

Address: _________________________________________________________________________

__________________________________________________________________________________

City: ____________________________________________ Post Code: _______________________

Telephone: Home: ___________________________ Work: ________________________________

Mobile: __________________________________

E-mail: ___________________________________________ Fax: ___________________________

Occupation: _______________________________________________________________________

How did you hear about us?....................................................................................................................

Are you interested in receiving any of the following treatments?

Wrinkle Softening Skincare Treatments Chemical Peels

Laser Tattoo Removal Laser Skin Rejuvenation Body Firming Treatment
Nutrition Colonic Hydrotherapy Hormone Balance

Area/s of Laser Treatment

*Please fill below together with your Skin Specialist

*******************************

SKIN TYPE:

Type Yes/No
I Always burns, never tan
II Always burns, sometimes tan
III Sometimes burn, sometimes tan
IV Always tan
V Hispanic, Asian, Mediterranean, Middle Eastern

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 VI Black

HAIR TYPE:

Colour: Blonde Red Brown Black

Thickness: Fine Medium Course

When where you last exposed to the sun (including tanning booths)?

Do you use chemical sun tanning lotions? When last did you use them?

Are you planning a holiday in the sun?

Method of hair removal on area treated?

Are you pregnant?

Do you have any of the following Are you on any of the

conditions? following medication?

Diabetes Y/N Anticancer Drugs Y/N

Blood disorder Y/N Antidepressants Y/N
Cardiac disorder Y/N Antihistamines Y/N
Malasma Y/N Antihypersensives Y/N
History of cancer Y/N Antimicrobials
Active infection Y/N Y/N
Herpes Simplex Y/N Antiparasitic Y/N
Systemic Lupus Erthematosus Antipsychotic Y/N
Y/N Diuretics Y/N
Hormonal/ Endocrine disorderY/N Herbal Medicines Y/N
History of Keloid scaring Contraceptive Y/N

NOTES:
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TREATMENT PAYMENT PLAN:

Treated Body Area Total Price Offer:

areas in separate rows Sessions
Example: Upper lip x6 £600

1.

2.

3.

4.

5.

6.

7.

Total Payment for Treatment(s): £……………….

Payment Notes: …………………………………………………………….

(if agreed to pay in one or more installment)

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Dear Practitioner: Please separate each treated area in separate rows and do not put down Full
Body! Thank you.

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PLEASE READ & SIGN:
The system is a device that produces an intense but gentle burst of light that treats the
targeted area without harming the surrounding tissue. To protect my eyes from the
intense light, I will have my eyes covered with an opaque material or wear laser
protective glasses.

Discomfort When the pulse is triggered, it may cause various degrees of discomfort.
Some describe the sensation similar to a snap of a rubber band.
The area may be sensitive 24 hrs. after treatment, similar to mild
sunburn.

Blister/ Crust There is always the slight possibility of developing crust or a blister.
This is superficial, does not result in any scarring.

Pigment changes Most cases occur in people with darker skin/ skin has been exposed to
sun. This discoloration usually fades in three to six months.

Swelling Immediately after treatment skin may swell temporarily. Swelling may
last anything from a few hours to seven days.

I understand that the Laser Treatment is intended for hair reduction and that clinical
results may vary in different skin types. For the best results, I have been informed that
multiple treatments will be necessary and it can not guaranty a permanent hair
removal.

I understand that HB Health has no refund policy and cannot give money back.

I understand that there is a possibility of rare side effects such as mild burning, blistering,
swelling and discoloration of skin and application of aloe vera gel or epidermal repair
cream may be necessary. Improper care of the treated area may increase the chance of
scarring or skin textural changes. This has been discussed with me.

I understand that all laser practitioners at HB Health of Knightsbridge have extensive

knowledge, expertise and experience however HB Health can not guaranty that my laser
course will be done by the same practitioner, there might be circumstances (Holiday or
sickness…etc) when the booked appointment/s will be with another, fully trained and
qualified therapist.
I consent to taking photograph(s) of my treated body area(s) for purposes of follow up
sessions and to see the results.
I have read and understood all information presented to me before signing this consent.
My questions were answered to my satisfaction. I agree with the terms and conditions of
this agreement.

Client name:……………………………….. Signature: ………………………………

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Practitioner’s name: ………………………. Signature: ……………………………..

Date: …………………..

POST LASER TREATMENT FORM

Prevent any sun exposure on the treated area.

Apply Sun Protection SPF 20 and higher daily to the area.

Avoid rubbing the treated area

If blistering or crusting occurs, then an antibiotic ointment of your choice may be

used as indicated.

Avoid hot baths or steam rooms 24 hrs after treatment

Avoid aerobic exercise for 24 hours after treatment

Do not wax area between treatments.

Client’s name: ……………………………

Signature: ………………………………

Practitioner’s name: ………….………… Date: …………………….

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