LightSheer QUATTRO
12211 Regency Village Dr. #10 Suite 5, Orlando, FL 32821
Phone: (321) 939-1093
I authorize Celebration Aesthetic Center to perform LightSheer QUATTRO treatments on me to improve:
I understand that there is a rare possibility of side effects or serious complications including permanent discoloration and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility.
During the procedure and shortly after, I might experience an itching sensation which degree will vary per condition treated, area sensitivity, and treatment head used.
This sensation does not last long and a mild "sun-burn" sensation may follow for typically up to one hour and might be reduced with application of cooling and soothing creams.
Severity and duration of the rash depend on the intensity of the treatment and the sensitivity of the area to be treated. These phenomena may be reduced with application of cooling and/or anti-inflammatory creams.
Typically dissipates within a couple of hours.
Over some areas with very dense and coarse hair/pigmented lesions, micro-crusting may take 5 to 10 days to flake off. It is important not to manipulate or pick, which may otherwise lead to scarring.
May rarely occur and may last several days.
I understand that sun exposure or tanning of any sort is not aligned with the pre and/or post-care instructions and may increase the chance for complications.
I agree to review the following laser pre-treatment compliance checklist and bring accurate and updated data, to the best of my knowledge.
Natural or artificial sun exposure in the past 3-4 weeks OR planning sun exposure in the following 3-4 weeks post-treatment?
Use of self-tanners or tan enhancer capsules within the past 3-4 weeks?
Taking photosensitive herbal preparations (St. John's Wort, Ginkgo Biloba, etc.) or using aromatherapy (essential oils)?
Diseases which may be stimulated by light at 805nm or 1,060nm, such as history of Systemic Lupus Erythematosus or Porphyria?
Pregnant, possibility of pregnancy, postpartum, or nursing?
Inflammatory skin conditions (dermatitis, active acne, etc.)?
Presence or history of active cold sores or herpes simplex virus?
Medical history of keloids?
History of livedo reticularis?
History of erythema ab igne?
Medical history of Koebnerizing isomorphic diseases (vitiligo, psoriasis)?
Any tattoo, permanent make-up, and/or dysplastic nevi on requested treatment area that should be protected?
HIV?
Active cancer (currently on chemotherapy or radiation)?
Previous skin cancer?
Hormonal or endocrine disorders (PCOS or uncontrolled diabetes)?
Intake of aspirin or anti-coagulants?
Easy bruising?
Swollen legs or pain after long standing/sitting?
Previous vein surgery on requested treatment area (sclerotherapy, stripping, etc.)?
Intake of isotretinoin (Accutane) within the past 6 months?
Previous hair removal procedures on requested treatment area (other IPL/laser, wax, electrolysis, etc.)?
If yes, within the past 6 weeks?
Previous skin procedures on requested treatment area (Botox, fillers, peels, metal implants, threads, etc.)?
One of the most important factors in deciding which Laser/IPL settings to use is the patient skin type. Skin typing is determined by genetics, reaction of the skin to sun exposure, and tanning habits. Please answer the following questions honestly.
1. What is the color of your eyes?
2. What is the natural color of your hair?
3. What is the color of your skin (non-exposed areas)?
4. Do you have freckles on non-exposed areas?
Genetic Predisposition Score: 0/16
5. What happens when you stay in the sun too long?
6. To what degree do you turn brown?
7. Do you turn brown within several hours after sun exposure?
8. How does your face react to the sun?
Sun Reaction Score: 0/16
9. When did you last expose your body to sun (or artificial sunlamp/self-tanning cream)?
10. Did you expose the area to be treated to the sun?
Tanning Habits Score: 0/8
Total Score
0/40
Skin Type
-
I consent to photos/videos for my personal treatment records only. These will not be shared or used for any other purpose.
I consent to anonymized photos/videos (face not shown, no identifying information) being used for Celebration Aesthetic Center's marketing and educational purposes.
I do not consent to any photos or videos being taken.
I consent to receive appointment reminders, aftercare instructions, promotional offers, and other communications via email.
I consent to receive appointment reminders and important notifications via text message.
Celebration Aesthetic Center requires a minimum of 24 hours' notice to cancel or reschedule a visit. Cancellations or reschedule requests MUST be submitted by calling (321) 939-1093. We thank you for your cooperation with this matter and your understanding of how last-minute cancellations or "no shows" restrict us from providing other clients with appointments.
Celebration Aesthetic Center reserves the right to collect credit card information upon time of scheduling and may charge you for the cost of treatment upon any missed services due to insufficient cancellation notice. "No shows" will automatically be deducted from your account.
Aftercare instructions must be followed explicitly, whether given in writing or orally. Failure to follow aftercare instructions may compromise the final results of the treatment.
I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Celebration Aesthetic Center, including its officers, members, owners, employees, and agents, from any and all damages, costs, expenses, liabilities, causes of action, claims, and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by Celebration Aesthetic Center. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under Florida law.
It is understood that any dispute arising as to malpractice of the Hair Removal treatment shall be decided by a neutral arbitrator. Any arbitration proceeding will be governed by Florida arbitration statute. The fees for the arbitrator will be split pro-rata among the parties, and each party will be responsible for their own attorneys' fees and costs. Any action to collect fees from the client/patient for the treatments performed may be brought in any court located in Florida.
By signing this agreement, I confirm that I am over the age of 18, I understand that the Hair Removal procedure stimulates permanent changes, that such procedure has possible adverse consequences, and that the procedure is for cosmetic purposes only. I certify that I have read the above paragraphs, fully understand this consent and procedure form, and hereby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the Hair Removal procedure. I hereby agree to arbitration of any malpractice claim. I further understand that by signing this agreement, I surrender certain legal rights.
I, the applicant for this form, warrant the truthfulness of the information provided in this form.