303.938.1666

IV SEASONS SKIN CARE
HANS R. KUISLE, M.D.
WINFIELD HARTLEY, M.D.
2525 4th Street, Suite 204
Boulder, CO 80304
(303) 938-1666
Fax: (303) 443-7124
www.drkuisle.com

LASER HAIR REDUCTION CONSENT FORM

I, ________________________________________authorize Hans Kuisle, M.D., Winfield Hartley, M.D. or their designated representative to perform the Laser Hair Reduction therapy to (designated body area)____________________________________________________________.                   

•  The hair reduction laser decreases the amount of hair regrowth by 60-80%.  

•  The treatment does not remove all hair permanently.  

•  Results depend on color and location of hair follicles.

•  6-12 treatments at 4-6 week intervals are required for maximum results.  

•  Follow up treatments are recommended.  

•  Often, not much change in the amount of hair or hair regrowth will be noticed after the first few treatments.  

•  5% of the population does not respond to laser hair reduction.  

•  Hyperpigmentation, hypopigmentation, and scarring are possible risks of this procedure, but are rare.

I understand that immediately following the laser treatment the area may appear red or bruised discoloration and swollen at the follicle.  

I understand that any discoloration may last up to 14 days and swelling may last for a few hours up to several days.   Improper care, such as picking at the hair while the discoloration is present may increase the chance of scarring or pigmention the area.   

I have read and understood all information presented to me before signing this consent .

        _______________________________________            __________________________

                                           Patient                                                                             Date

       ________________________________________            _______________________AM / PM

                                    Witness                                                                      Time

                                                                                                                                                                             9/04Ash