Home » About » Consent Forms » Laser Hair Removal Consent Form
LATENESS & CANCELLATION POLICIES
I do understand our lateness, cancellation, and rescheduling policy are as follows:
Please arrive ON TIME for your appointment. Delayed arrival will limit the time of your experience, reducing the effectiveness of your treatment and the expectations of your visit. In consideration of other guests, service time will not be extended for late arrivals and in MOST cases you will not be treated, due to our limited space capacity and time slots thereafter being filled.
There is a five (5) minute grace period for late arrivals. IF YOU ARE more than 5 minutes late we CAN NOT treat you, as noted due to our limited space capacity and appointments that follow.
You must cancel or reschedule your appointment 24 hours BEFORE your appointment date and time. A full 24 hours notice must be received before your appointment.
Failure to provide such notice will result in a $30 fee for standard services or a $60 fee for full body; charged the day of your missed appointment to your card on file.
If you do not show up for your appointment the same day, rescheduling fees as listed above also apply - $30 fee standard services or $60 fee for full body.
CREDIT CARD & PAYMENTS
A valid credit card is required to be kept on file while your treatment sessions are active to cover cancellation, rescheduling and membership fees.
We are not able to book any appointments without a credit card on file. This applies to all package types including Groupon, Gilt, Pulsd.. etc..
All treatments require an initial payment in order to book an appointment.
Monthly payment plans must be made on time, late monthly payments will result in cancelation of all upcoming appointments.
TREATMENT & RESULTS
I understand I need to FULLY shave (to the skin level) ALL areas that are to be treated a night before of my scheduled appointment, the Spa CAN NOT shave you the same day. DO NOT SHAVE ON A DRY SKIN.
I do understand that if I fail to shave the night before my appointment, I will NOT be treated, and same day rescheduling fees apply.
I understand that to achieve maximum and safe results the protocol prescribed in the Madison Laser Spa “BEFORE + AFTERCARE” document MUST be adhered to.
I understand that I must stop tweezing, waxing, bleaching, using depilatories or any substance/medication that will damage the hair follicle.
I understand the Inova Laser system is intended for hair removal and that clinical results may vary with different skin types, hair color, and body location. I understand there is a possibility of rare side effects, such as scarring and permanent discoloration; as well as short-term effects, including redness, mild burning, blistering, temporary bruising and discoloration of the skin, such as hypo pigmentation (decrease in skin pigment) or hyper pigmentation (increase in skin pigment). These effects have been fully explained to me.
I fully understand and I am aware that if I am taking any medication(s)/antibiotics that cause photosensitivity, I will be exposing myself to the risk of getting scarred or burned while undergoing my laser hair removal treatments.
I understand that I cannot use acne topical creams, including Retinol and Chemical Acids. If you have used, you cannot be treated and same day rescheduling fee will apply.
I understand excessive sun exposure needs to be avoided two weeks before and two weeks after each treatment. For optimal results, I should attempt to maintain the same skin tone throughout the treatment process. Sun exposure, tanning beds or the use of self tanning products could result in a less effective treatment. If you have had sun exposure, the technician will evaluate your skin, and may not be able to perform the treatment. I will use sunscreen while tanning for the duration of my laser hair removal treatments.
I understand that any area with a tattoo or permanent make-up cannot be treated.
I understand that laser hair removal is not 100% permanent and is in fact a reduction of up to 90%.
I understand that to achieve maximum results the protocol prescribed that has been given to me in the before and after care should be adhered to.
I understand that this procedure works on the growing hair follicles, not dormant hair. For this reason, complete destruction of all hair follicles from any one treatment is unlikely. Every individual has between 500 and 1000 follicles per square cm, of which many could be dormant. There is no way of knowing if and when they may start growing, so treatment results may vary and range in the number of treatments to achieve desired results or may be minimal or not help at all.
The treatment schedule is designed to maximize the results of each hair cycle. If for any reason the schedule cannot be adhered to, I understand that the total percentage of hair loss could be affected. In addition, hair follicles that are dormant now may become active during or after my treatment program and additional treatments may be necessary. I also understand that I will have to pay for these additional treatments.
I understand that treatment by the Inova Laser hair removal system involves a series of treatments and the fee structure has been fully explained to me.
I confirm that I am not pregnant or breast feeding at this time and I will inform Madison Laser Spa if I become pregnant or breast feeding in the future; and all laser treatments must be stopped immediately.
I agree that I will NOT ask the Technician to laser any area that has not been paid for, nor ask for any body part to be lasered that is not permitted by the Spa. (i.e. in between eyebrows and above)
I agree to conduct respectful, polite behavior with all staff.
Male clients can only be treated in a flaccid state (soft and hanging loosely)Technicians will not handle male genitals.
TAXES & GRATUITIES
I do understand that taxes and gratuities are NOT included in any service I purchase. It is common practice to tip after EACH treatment 15 - 20% of the original service price. Gratuities are accepted in the form of cash, venmo or zelle and go directly to the Technician that treated you.
CHANGE OF TREATMENT AREA
You may only change the area of treatment after the FIRST session. If the change to the treatment area is higher in price, applicable fees for the difference must be paid. There is no refund when you change to a lower priced package. No exception can be made; you may only change the area after the first treatment.
I understand that ALL SALES ARE FINAL and non-refundable.
We will only exchange the value of the treatment price/package purchased towards another treatment. The exchange must be done before your first treatment begins. We will credit the purchased amount towards the amount of the full price of the new treatment area you would like to exchange (for equal or greater value).
FINAL TREATMENT CONSENT
I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes, and possible complications. I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
I have read and understand this agreement and all my questions have been addressed and answered to my satisfaction. I consent to the terms of this agreement.
PLEASE SELECT WHO WILL BE PARTICIPATING:*
Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe
What oral medications are you presently taking?*
Birth Control PillsHormonesNone
Others (Please list):
Are you on any mood-altering or anti-depression medication?*
If Yes, when did you last use it?
Have you ever used Accutane?*
If Yes, when did you last use it?
What topical medications or creams are you currently using?*
Others (Please list):
Have you ever had laser hair removal?*
Have you used any of the following hair removal methods in the past four weeks IN THE AREAS THAT WILL BE LASERED?*
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
Have you recently used any self-tanning lotions or treatments?*
Do you form thick or raised scars from cuts or burns?*
FOR OUR FEMALE CLIENTS:
Are you pregnant or trying to become pregnant?*
Are you breastfeeding?*
Are you using contraception?*
I certify that the preceding medical, personal and skin history statements are true and accurate. 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. Current medical history is essential for the caregiver to execute appropriate treatment procedures.
CLIENT INFORMATION & LASER/MEDICAL HISTORY:
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.
Which of the following best describes your skin type?*
Choose OneAlways Burns, Never TansAlways Burns, Sometimes TansSometimes Burns, Always TansRarely Burns, Always TansBrown, Moderately Pigmented SkinBlack Skin
Are you currently under the care of a physician?*
If yes, for what:
Are you currently under the care of a dermatologist?*
Do you have any of the following medical conditions?* (Please check all that apply)
CancerDiabetesHigh Blood PressureHerpesArthritisFrequent Cold SoresHIV/AIDSKeloid ScarringSkin Disease/Skin LesionsSeizuresHepatitisHormone ImbalanceThyroid ImbalanceBlood Clotting AbnormalitiesAny Active InfectionNone
Do you have any other health problems or medical conditions?
If so, please list:
Please note any coupon deals:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
764 Madison Ave 3rd floorNew York , NY, 10065
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