LASER HAIR REMOVAL INFORMED CONSENT, WAIVER & PATIENT INTAKE FORM
Patient Medical & Skin Questionnaire
Personal Information
Male
Female
Medical History
Heart disease
Diabetes
Hormonal disorders
Epilepsy / Seizures
Cancer
Autoimmune disorders
Pacemaker / Defibrillator
Pregnancy / Breastfeeding
Blood clotting disorders
HIV / Hepatitis
Skin & Laser History
Photosensitivity
Skin cancer
Keloid scarring
Pigmentation disorders
Chemical peel (recent)
Botox / fillers (2 weeks)
Waxing / plucking (4 weeks)
Electrolysis
Previous laser
Recent sunburn / tanning
Sun Exposure Profile
Always burn, never tan
Burn easily, tan minimally
Burn moderately, tan gradually
Rarely burn, tan easily
Never burn, tan very easily
Use sunscreen regularly?
Yes
No
Client Acknowledgment
Informed Consent for Laser Hair Removal
I voluntarily request and consent to receive laser hair removal treatments provided by Kley Laser.
I understand that laser hair removal uses concentrated light energy to target hair follicles and that multiple sessions are required for optimal results. I acknowledge that results vary based on hair type, skin type, hormonal factors, and individual response.
I understand that laser hair removal is a cosmetic procedure, not a medical treatment, and permanent hair removal is not guaranteed.
Medical & Treatment Disclosure
Allergies or skin sensitivities
Skin disorders or scalp conditions
Pregnancy or breastfeeding
Hormonal disorders
History of photosensitivity
Use of Accutane (Isotretinoin) within the past 12 months
Use of antibiotics or medications that increase light sensitivity
Recent sun exposure, tanning beds, or self-tanners
Previous laser or IPL treatments
Failure to disclose accurate information releases the provider from responsibility for any adverse outcomes.
Assumption of Risk
Redness, swelling, or discomfort
Blistering or burns
Hyperpigmentation or hypopigmentation
Scarring (rare)
Incomplete or uneven hair reduction
Reactivation of herpes simplex (cold sores)
Infection (rare)
I accept these risks even if caused by ordinary negligence to the fullest extent permitted under Texas law.
Release & Waiver of Liability (Texas)
I release, waive, discharge, and hold harmless Kley Laser, its owners, operators, employees, contractors, and affiliates from all claims related to laser hair removal services.
No Refund / No Guarantee / No Chargeback
All treatments and packages are non-refundable
No refunds for unsatisfactory results
No chargebacks or payment disputes
Missed or late appointments may be forfeited
Dispute Resolution & Arbitration
All disputes shall be resolved by binding arbitration in the State of Texas. Jury trial is waived.