Consent Form Consent Form IPL, Laser, Tatoo Removal, Fat Loss, RF Treatments Step 1 of 3 33% Name* First Last Date of Birth*Your date of birth DD MM YYYY Address* Street Address City ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Email* Mobile Phone*Gender*FemaleMaleTrans-Gender (Male to Female)Trans-Gender (Female to Male)How did you hear about us?*Walk pastLeafletInternet SearchSocial MediaRecommendationOtherWhich treatment are you having?* Hair Removal Skin Rejuvenation Thread Vein Removal Pigmentation Removal Acne Clearance Wrinkle Reduction Tattoo Removal Birthmark Removal Fat Freeze Laser Lipo Ultrasonic Cavitation Fat Loss Radio Frequency Skin Tightening Teeth Whitening List all areas you are having treated*E.g legs, arms, stomachHave you used any of the following in the past 30 days?*Some machines are not suitable if you have had the below within 30 days.NoneSun bedsSelf tanning creamTanning in the sun Do you have any medical conditions listed?Select NONE or leave blank if it does not apply to you NONE Hirsutism Polycystic ovarian syndrome Port wine stain Melanoma Haemangioma Anti-inflammatory medication Herpes (or cold sores) Thyroid hormone deficiency Hormonal Imbalances Diabetes Heart Disease Burns / Grafter skin Cancer (or radiation/chemotherapy) Keloid formations / Scars Liver / Kidney disease Epilepsy Psoriasis Shingles Steroid of Hormonal therapy Vitiligo Aids Lupus Disease Pacemaker Haemophilia Clotting disorders Anti-coagulants Pregnant Breast Feeding Specify a medical condition that is not listed aboveLeave blank if not applicableList any medication that you are takingLeave blank if not applicableAre you currently using Retin A or Glycolic Acid?*YesNoAre you currently using Roaccutane*YesNoHave you recently had a chemical peel?*YesNoWhat products are you currently using on your skin (including body products)?Leave blank if not applicableIf you have an implant, list the area of the implantLeave blank if not applicableList any particular skin sensitivities or allergies that you haveLeave blank if not applicableList any major surgery you had in the last 3 months?Leave blank if not applicable INFORMED CONSENT I hereby authorise Laser Cosmetics to treat me using the AW3® system. I understand that the reduction/ removal may not be 100%. I also understand that the treatment using the AW3® system may need to be performed in repeated sessions in the future to obtain optimal results. I have been informed about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have. I understand that there are certain risks associated with the treatment and they include but are not limited to the following: • Post-treatment discomfort like localised swelling, redness and mild tenderness. • Although uncommon the treatment may cause blisters or light burns to the surface of the skin. (Light /Laser Treatment Only) • Transient hypo or hyper pigmentation may occur and will normally fade in 3 to 6 months. • Crust formation “dirty skin” look is commonly seen for up to 10 days after treatment. (Light /Laser Treatment Only) • Scabbing, Swelling, and bleeding can occur but these are temporary. (Light /Laser Treatment Only) Below are a list of treatment(s) that will apply to me when accepting this consent. 1) Hair Removal: Intense Pulsed Light / Laser treatment is a method of treating unwanted hair. Unwanted hair may be caused by medical conditions such as hirsuitism, hypertrichosis and other disorders. Treatments using the AW3® System will not cure any medical conditions causing unwanted hair. The purpose of the treatment is to achieve cosmetic improvements by reducing hair growth by using Intense Pulsed Light /Laser to destroy hair follicles. 2) Thread veins /Pigmented lesions- Using the AW3® Intense Pulsed Light / Laser system is a method of treating vascular and pigmented lesions. The purpose of the treatment is to achieve cosmetic improvements using Intense Pulsed Light/ Laser to destroy vascular and/or pigmented lesions. 3) Skin Rejuvenation/ Acne Treatment- Intense Pulsed Light /Laser treatment is a method of treating sun-damaged skin. Over exposure to UV light can cause mottled/uneven pigmentation, open pores, sunspots and damaged blood vessels. Treatments using the AW3® system will not cure any medical conditions causing pigmentation or thread veins. The purpose of the treatment is to achieve improvements in the appearance of the skin by improving skin colour, tone and pore size using Intense Pulsed Light /Laser to target excess pigmentation and thread veins. 4) Wrinkle Reduction- Intense Pulsed Light / Laser treatment is a method of treating superficial fine lines and wrinkles. Everyday aggressors and skin ageing are some conditions that influence the skins collagen network and appearance. Treatments using the AW3® system will not cure any medical conditions causing fine lines and wrinkles. The purpose of the treatment is to achieve improvements in the appearance of the skin by improving collagen production within the dermis so therefore aiding in the skin turgor, texture and pore size using Intense Pulsed Light/ Laser. 5) Laser Tattoo Removal/ Pigmentation/ Birthmark Removal Laser treatment is a method of removing tattoos. The purpose of the treatment is to achieve improvements in the appearance of the skin by removing the unwanted tattoo/pigment within the dermis of the skin using the AW3® Laser system. 6) Laser Lipo/ Cavitation / Cryolipolysis The AW3® fat loss treatment is a method of removing fat /cellulite. Everyday lifestyle, diet and lack of exercise can influence production of fat and the body appearance. Treatments using the AW3® System will not cure any medical conditions or alter the natural production of fat to your body. The purpose of the treatment is to achieve improvements in the appearance of the body or skin tightening by removing unwanted fat and reducing the area in size, the result do vary from person to person. As part of the programme, regular exercise and good diet will aid the treatment to work more effectively. 7) Radio Frequency Skin Tightening AW3® radio frequency technologies used to tighten and induce collagen production for skin tightening, wrinkle reduction, acne scarring and to minimize pores. The radio frequency produces two or three currents depending on whether it is bipolar/ tripolar /multipolar which alternate high and low frequency currents no less than a thousand times per second. This heats the deeper skin tissues to promote blood circulation to tighten the skin. At the same time, the cooling measures are taken on the skin surface by applying cooling ultrasound gel. The purpose of the treatment is to achieve improvements in the appearance of the skin tightening. The dermal layer of the skin becomes thickened, with the new collagen production and the wrinkles are pushed out, so the skin become firmer and the contours are lifted.Accepting Terms and Consent*I agree to follow the post treatment recommendations advised by operator/company above in order to ensure the best possible results. For Light/ Laser Treatments, I understand that excessive heat should be avoided for 48 hours and that exposure to the sun, including sun beds, must be avoided for 30 days before treatment and 30 days after treatment. (AW3 Super IPL and AW3 Super Laser may vary and your specialist can advise) A sun block of SPF 30+ must be used on the exposed skin areas, otherwise it might be possible that blotchy skin pigmentation, hyper- or hypo-pigmentation might occur. I agree to co-operate with the recommendations of the company or the personnel while I am under their care, realising that any lack of co-operation could result in less than optimum results. I agree to inform the above operator/company immediately if any adverse effects occur. I agree to photographic documentation of the treated area prior to treatment. I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure. I agree to pay for the above mentioned services and understand that there will be no refunds for any performed services. This consent form and cost covers above selected treatments only. Additional treatments can be added to this consent form and will be charged for as per clinic price list, including single shot treatments. I have been made aware of the risks and I accept these terms and conditions as part of my treatment. We accept no liability for any of the above side effects. By accepting this, I agree to the terms and conditions and in the event of any of the above. I or any of my representative will not pursue the above person / company in any means of compensation. I've read and accept the consent CaptchaBy entering this captcha confirms the above information is true and you have understood all the terms.