Intakeformulier Voornaam(Vereist)Achternaam(Vereist)Straat + huisnummer(Vereist)Postcode(Vereist)Plaats(Vereist)Geb. datum(Vereist) DD slash MM slash JJJJ E-mailadres(Vereist) Telefoonnr(Vereist)What are your previous treatment methods(Vereist) None Shaving or depilatory cream Waxing Epilation or epilator Electric hair removal Other IPL or laser treatments How long has the hair been present and when did it arise?What are your expectations?Have you been exposed to the sun, tanning bed or spray tan in the past 4-6 weeks?(Vereist) Yes No Have you had a skin-enhancing treatment in the treatment area in the last 2 weeks?(Vereist) Yes No Have you used products with Retinol or Benzoyl Peroxide in the past week?(Vereist) Yes No Do you have Botox/fillers?(Vereist) Yes No How long ago?Medical backgroundAny form of cancer or skin tumors?(Vereist) Yes No Such as:Last chemotherapy or radiation treatment:Allergies, such as hypersensitivity to light or histamine reactions?(Vereist) Yes No Such as:Are there any skin diseases caused by the Herpes Simplex virus, such as cold sores or genital warts?(Vereist) Yes No Such as:Skin diseases, such as psoriasis, eczema?(Vereist) Yes No Such as:How is your wound healing?(Vereist) Good Delayed Keloid formation Use of medicines, such as Roaccutane (Isotretinoin) or antibiotics?(Vereist) Yes No Such as:Last time used:Any use of other medicines, vitamin preparations or homeopathic remedies?(Vereist) Yes No Such as:How long should you take it?Hormonal imbalances, such as lower estrogen or higher androgen?(Vereist) Yes No Such as:Are there any endocological diseases, such as disorders of the thyroid gland, adrenal glands, ovaries or diabetes?(Vereist) Yes No Such as:Any use of birth control?(Vereist) Yes No N/A An infection or inflammatory diseases?(Vereist) Yes No Such as:Immune diseases?(Vereist) Yes No Such as:Heart, blood or clotting diseases, such as high blood pressure or thrombosis?(Vereist) Yes No Such as:Do you have varicose veins or other vascular problems?(Vereist) Yes No Neurological disorders, such as epilepsy?(Vereist) Yes No Such as:Do you agree that we take before & after photos to assess the progress of your skin and share them on Social Media (without facial recognition)?(Vereist) Yes No Any commentsHow did you come to us?(Vereist)Make your choiceFamily friendsSocial MediaGoogleOtherwiseHow did you end up at The Laser Bar?Waarheid(Vereist) I have answered all questions truthfully. City(Vereist)Date(Vereist) DD slash MM slash JJJJ Consent and agreement(Vereist) I give permission and agree to the Informed Consent below INFORMED CONSENT LASER Lumenis Lightsheer Desire and/or Candela GentleMax Pro laser in an attempt to reduce unwanted hair growth and/or treat pseudofolliculitis barbae. Laser hair removal of thick and dark hair on light skin gives the best result. With thinner hair and hair with less pigment (such as blond, gray and red hair), the treatments will be less effective. There is a chance of side effects, such as permanent skin discoloration and scarring. Risk is a disappointing cosmetic result. I am aware that careful adherence to all advised instructions will help reduce this possibility. I understand the list of temporary effects and skin reactions below and I am willing to follow the instructions given by the laser specialist: 1. Discomfort: During and immediately after the treatment, a tingling heat sensation may be experienced, depending on the hair density, treatment head and sensitivity in the treatment area. A mild 'sunburn' sensation may occur and usually last for an hour. Cooling the skin and/or using a soothing cream will reduce this. 2. Redness and swelling around the hair follicles: severity and duration depends on the treatment intensity and sensitivity in the treatment area. This will be reduced by cooling the skin. 3. Scab formation can occur in areas where there are thick stiff hairs, this takes about 5 to 10 days, then the scabs fall off. It is important not to scratch or pick at the scabs because of scarring. With both lasers, avoidance of sunlight, the use of tanning beds, spray tans and tanning creams is necessary for at least 6 weeks before and 6 weeks after the treatment. It is important to use a good sun protection with an SPF 50 several times a day. If this advice is not followed, there is a higher risk of blocked depigmentation, pigment shift, burning and scarring. Sauna visits, hot showers and/or intensive sports are not allowed 48 hours after the treatment. The treatment procedure was explained to me. I have been informed that, despite the prospect of good results, the likelihood of complications and the nature of complications can never be accurately predicted and therefore no guarantees, either express or implied, can be given with regard to the success or other outcomes of treatment. The following complications can occur: The appearance of blisters / extreme redness of the skin due to too much heat development. The appearance of light and/or dark pigment spots. Increase of hair growth due to the heat in the skin, inactive hair follicles can be activated by this. In exceptional cases, the laser therapy may not work (properly), the cause could be a fluctuation in hormones. A small percentage of the population (3-9%) is a non-responder, the cause of which is unknown. I hereby declare that I have read this consent form and that I understand the information. I have had the opportunity to ask questions regarding the treatment and these have been answered to my satisfaction. The before and aftercare instructions have also been explained to me, and I will follow the advice given. I hereby also declare that I have not concealed any information that could influence the result of the treatment. Payment Terms for Packages By purchasing treatments and/or packages at The Laser Bar you agree to our general terms and payment conditions. When you choose to purchase a package, you have the option to pay the full amount in one payment or in installments. Please note that all payments made, whether deposits or full payments for packages, are final. This means we do not offer refunds on amounts already paid, regardless of whether you ultimately choose not to complete or use the full package (or part of it). By signing this form, you acknowledge that you have been informed of this and that you agree to these terms.Signature(Vereist)Important: A parent or guardian's signature is required for minors.
