All questions contained in this questionnaire are strictly confidential and will became
part of your medical record

ALLERGIES

MEDICATION HISTORY

MEDICAL CONDITIONS

TERMS & CONDITIONS

I here by authorize Laserology trained, certified sta to perform Laser based hair
reduction on me.

• I understand that this procedure works on the growing hairs (anagen) and not on dormant hairs.
• I understand that I will require several treatments of any mentioned above laser treatments to obtain a significant, long-term reduction of hair growth.
• I understand I may experience fewer, thinner, lighter, slower re-growth of hairs temporary hair loss or permanent hair reduction.
• I understand that it is only eective on hair with color and does not treat white, grey, blonde, or red hair.
• I understand that genetics, hormones, medication and hair color may interfere with hair loss and that I may not respond at all.

The procedure may result in the following adverse experience or risks:

• DISCOMFORT/PAIN
  Discomfort and/or pain may be experienced during treatment.
• REDNESS/SWELLING/BRUISING
  Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.
• HYPOPIGMENTATION/HYPERPIGMENTATION
  During the healing process, there is a slight possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary but on a rare occasion, it may be permanent.
• WOUNDS
  Treatment can result in burning, blistering, or bleeding of the treated areas.
• SUN EXPOSURE/TANNING BEDS/ ARTIFICIAL TANNING
  May increase the risk of side effects and adverse events.
• INFECTION
  Infection is possible whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness.
• PARADOXICAL HAIR GROWTH
  Stimulation of terminal hair growth following photo-epilation. Can occur within or adjacent to the treated area.
• SCARRING
  Scarring is a rare occurrence, but it is possible. This can be further complicated if the skin surface is disrupted. To minimize the chances of scarring, you must follow all post- treatment instructions provided by your health care sta.
• LEUKOTRICHIA
  Temporary or permanent gray hair.
• EYE EXPOSURE LEUKOTRICHIA
  Temporary or permanent gray hair. Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage

IF ANY OF THESE OCCUR, PLEASE CALL OUR OFFICE at +62 812 39 400 338.

I acknowledge the following points have been discussed with me :

• Potential benefits of the proposed procedure, including the possibility that the
  procedure may not work for me.
• Alternative treatments such as electrolysis, waxing, plucking, and depilatories.
• Reasonably anticipated health consequences if the procedure is not performed.
• Possible complications/risks involved with the proposed procedure and subsequent healing period.