Informed Consent to Treat: Laser Treatments
I _______________________________have been informed of the risks associated with cosmetic laser services
including; hyper and hypopigmentation, burning, scarring, blistering, redness, swelling, itching and other similar sideeffects and reactions.
Side effect may be due to:
O UV exposure on the treatment area(s) less than 7 days prior/post to treatment
O UV burns 2 weeks prior to my treatment.
O Application of any self-tanning products within the last 7 days.
O Medical Conditions ex: PCOS
O New topical or oral medications or skin care programs
 Retin-A (acne treatment), salicylic acid, beta/alpha hydroxyl acids, benzyl peroxide other similar
prescription or over-the-counter products in the last 7 days.
O Pregnant or on menstrual cycle.
O Elevated body temp 2 hours prior/post to this treatment
If any of the above statements are accurate then I understand that Studia Laser Institute strongly recommends I
reschedule my treatment. If I choose to continue with my treatment then I accept:
O The increased likelihood of experiencing the side-effects listed above; and
O The increased likelihood that I will not receive optimal results from this treatment; and
O That my money will not be refunded due to side-effects or lack of desired results.
I understand that this Studia Laser Institute location is owned and operated by CDMN Enterprises, LLC. I acknowledge
and agree that my only recourse for liability from any and all injuries, damages, claims or losses of any kind arising
out of this Agreement or the services received or products purchased from Studia Laser Institute/CDMN Enterprises,
LLC lie only against CDMN Enterprises, LLC.
Student Signature______________________________________________________________Date______________
Client Signature________________________________________________________________Date______________
Date__________________________
Date__________________________
Date__________________________
Sun exposure:
no/yes
Sun exposure:
no/yes
Sun exposure:
no/yes
Conditions:
no/yes
Conditions:
no/yes
Conditions:
no/yes
Topical/ Medication:
Adverse reaction:
no/yes
no/yes
Topical/ Medication:
Adverse reaction:
no/yes
no/yes
Topical/ Medication:
Adverse reaction:
no/yes
no/yes
Notes:________________________
Notes:________________________
Notes:________________________
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Client Initials___________________
Client Initials___________________
Client Initials___________________
Tech. Initials___________________
Tech. Initials___________________
Tech. Initials___________________
© Studia Laser Institute/CDMN Enterprises, LLC 12/7/12
Date__________________________
Date__________________________
Date__________________________
Sun exposure:
no/yes
Sun exposure:
no/yes
Sun exposure:
no/yes
Conditions:
no/yes
Conditions:
no/yes
Conditions:
no/yes
Topical/ Medication:
Adverse reaction:
no/yes
no/yes
Topical/ Medication:
Adverse reaction:
no/yes
no/yes
Topical/ Medication:
Adverse reaction:
no/yes
no/yes
Notes:________________________
Notes:________________________
Notes:________________________
______________________________
______________________________
______________________________
Client Initials___________________
Client Initials___________________
Client Initials___________________
Tech. Initials___________________
Tech. Initials___________________
Tech. Initials___________________