Laser Hair Regrowth Consent Form

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

I, Dr. , hereby inform the patient, , about the laser hair regrowth procedure. The patient has expressed an interest in this procedure and has requested information about the treatment.

Laser hair regrowth is a non-invasive treatment that uses low-level laser therapy to stimulate hair follicles and promote hair growth. The procedure involves the use of a medical laser device to target the affected areas. This treatment is designed to stimulate blood flow to the hair follicles, which may result in improved hair growth, hair thickness, and overall hair health.

Benefits:
- Improved hair growth
- Thicker and healthier hair
- Non-invasive procedure

Risks and Potential Complications:
- Redness or irritation of the scalp
- Itching or discomfort at the treatment site
- No guarantee of specific results
- Rare adverse reactions

The treatment plan will be discussed and agreed upon by the patient and the provider. This plan may include the number of sessions, frequency of treatment, and any other relevant details.

I, the undersigned, have read and understood the information provided to me regarding the laser hair regrowth procedure. I have had the opportunity to ask questions and have received satisfactory answers. I hereby give my informed consent to undergo the laser hair regrowth treatment.

I Understand that:
- The results of the procedure may vary from person to person.
- There are potential risks and complications associated with the procedure.
- The treatment may require multiple sessions.
- The treatment's success is not guaranteed.

I Acknowledge that no guarantees have been made regarding the outcome of the procedure.

Name of Patient:
Signature:

I, Dr. , have discussed the laser hair regrowth procedure, its benefits, risks, and potential complications with the patient, . I have provided the patient with an opportunity to ask questions and have obtained their informed consent for the Procedure.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :