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Informed Consent - Laser Hair Removal

 

IMPORTANT : Starting January 2019, in order to improve customer satisfaction and avoid miscommunication, we NO LONGER accept phone reservation or rescheduling. You can reach us directly by Text(551) 230-6569 or email us care@baredmonkey.com. Please save our phone number and email as point of contact. 

 

ACKNOWLEDGMENT, WAIVER, AND CONSENT TO RECEIVE LASER PROCEDURES. DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS. 

 

1. Company Policies:

 

Cancellation Policy:

 

I do understand the  24 hours prior notice (48 hours prior notice for appointment takes over 1/2 hour) is required to cancel or reschedule of my designated appointment, and $20 or ($40 for appointment takes over 1/2 hour) cancellation fee will be applied ifI fail to cancel or reschedule within the specific time frame. The same rule applies to NO SHOW appointments. As a courtesy, we will send email reminder/ text message to confirm your service appointments two business day prior to your appointment date. Please understand that it is your responsibility to text or email us when you need to modify your appointment to avoid the cancellation fee.

***Please save our text number (551)230-6569 /email address  care@baredmonkey.com as point of contact***

 

Online Promotion Voucher from Third Party:

 

  • Limit to one voucher per person per 12 months, additional purchase or gifted voucher(s) will not be honored but it can be either used as store credits or refunded through online merchant.
  • Limit to selective treatment areas  (XL areas will be excluded from any promotional package) if the desired treatment area is not on the “AREA SELECTIONS LIST”, client can exchange or upgrade the package in the store.
  • All treatments MUST be used on the same area and on the same person.
  • Voucher will be redeemed and sales tax will be collected after completing the first treatment. 

 

Shaving Policy:

 

Clients should have a CLEAN SHAVE one day before their appointment(s). It allows the maximum amount of laser energy penetrate to burn the hair follicles instead of hair shafts. Fail to shave will be subject to rescheduling or a shaving fee. ($15 for small area, $20 for medium area, $30 for large area, price may vary for extra large area.)

 

Refund Policy:

 

I do understand all sales are final and nonrefundable. There will be no refund or reimbursement to the unfinished yearly package(s), voucher, or deals if you become ineligible for laser treatment or physically impossible to continue the treatment within the stated period. 

 

Tipping:

I do understand that taxes, gratuities and shaving fees are NOT included in any service I purchase. Tipping is not mandatory but it is customary in most circumstances for service. It's generally good form to tip 10%-20% of the service fee. Gratuities are accepted in the form of cash or credit card.

 

 

   

 

2. Laser Treatment Informed Consent

 

  • I authorize Bared Monkey Laser Spa to perform laser hair removal procedure on me. I understand that this procedure works on the growing hair and not on dormant hair. Complete removal of all hair follicles is unlikely.

 

  • I understand that the clinical results and total numbers of treatments will vary between individuals depending on individual hormonal level, skin type, hair type, hair density, hair coarseness, age, genetics, medical conditions and other factors. Typically most of the clients require a minimum of 6 to 8 sessions to achieve a long-term, stable reduction in hair growth. For hormonal areas, such as face, bikini area, men's chest or back may require more sessions, and consistent touch-up may be necessary for these areas. 

 

  • I understand that laser hair removal is not exactly permanent as our body will continue to repair the damaged hair follicles and future hormonal changes may stimulate new hair growth, therefore, it's important to follow up after the full initial round of laser treatments to maintain the optimum result.

  • I understand that grey, blonde, red hair cannot be treated with the laser. There is limited result for fine hair (peach fuzz). In some cases, this can reactivate dormant hair follicles and induce new hair growth. 

 

  • I understand that tanning over the course of treatments is not recommended and can cause a number of complications. Scheduled treatment may be postponed if the patient is tanned. Tanning and sun exposure should be avoided 2 weeks before and 2 weeks after each treatment. Sunblock with SPF 50 or higher should be used on treated area during the course of laser treatments. It is my responsibility to inform the treatment provider if the skin is darker than when treatment was first started as well as any medical or prescription changes during the course of treatments. Improper post-treatment care may increase the chances of any complications.

 

  • I understand that If I am pregnant/breastfeeding, I am NOT a good candidate for laser. 

 

  

 

3. Alternative Procedures

 

Laser Hair Removal (LHR) is a non-invasive laser treatment designed to remove unwanted hair from all parts of the body. It's one of the best options to reducing and slowing hair growth over an extended period of time. During LHR, the laser emits a light that is absorbed by the melanin in the hair and light energy is converted to heat which damages hair follies and inhibits or delays future hair growth. We carried three different top of the line FDA cleared Laser Hair Removal equipments, ALMA Soprano, Candela Gentle Max Pro, Lumenis Splendor X, and we offer different types of laser wavelengths, Alexandrite Laser, ND-YAG laser and Diode Laser to help our clients to achieve the best results with safety and comfort level in mind. Here are the differences among 3 laser wavelengths: 

 

The ND-YAG (1064nm) laser has the longest wavelength, which is safer to treat clients with Skin Type V and VI (deeper skin complexity) and more effective to treat deeper embedded hair follicles due to deeper penetration. It’s gentle to treat all skin types. However, it is less effective on light-pigmented hair. It causes more discomfort during treatment, usually numbing cream is recommended. Cooling is provided with the DCD Cryogen freezing spray (Candela Gentle Max Pro), or cool air from Zimmer (Lumenis Splendor X).

 

The Alex (Alexandrite) (755nm) laser has shorter wavelength which is the most effective to treat light-pigmented hair/superficial hair follicles due to high melanin absorption. However, it involves a higher risk of injury of epidermal skin due to its superficial penetration. Not suitable for clients with Skin Type V to VI or tanned skin. Cooling is provided with the DCD Cryogen freezing spray (Candela),  or cool air from Zimmer (Lumenis Splendor X).

 

The Diode Laser (810nm) laser is more effective for Terminal Hair (longer, coarser and darker hair). There are limited results on Vellus hair (short and fine with little or no pigment hair), and less effective on skin type V and VI. It allows a more comfortable treatment due to its groundbreaking technology- the sweeping In-motion™ technique of moving the applicator repeatedly over the treatment area ensures full coverage while ICE™ technique cools the skin surface preventing superficial burns, yet highly effective hair removal. Usually, the numbing cream is NOT required in general. Cooling is provided with water contact cooling system (ALMA Soprano) and combined with a cooling gel.

 

LHR is a voluntary cosmetic procedure which is not necessary or required, here are other alternatives for hair removal practices: Electrolysis, waxing, plucking, threading etc. 

 

 

4. Contraindications of Laser Hair Removal

 

You may not be the best candidate for laser hair removal if any of the following contraindications pertain to:

  • Hormonal imbalance, PCOS, Hirsutism, pregnancy, menopause, and other endocrine conditions can affect the treatment outcome.
  • Pregnancy and nursing
  • Use of Accutane (must discontinue use of product 6 months before beginning treatment)
  • Use of photosensitive medications (i.e. Anti-biotic, Retinoids or other Acne medications, Antihistamines, Cancer chemotherapy drugs and other cancer drugs, Diabetic drugs, Statins, Malaria medications, Cardiac drugs, St. John Wort etc.) may cause an increased risk of side effects to the laser (must discontinue use of product 4 weeks before beginning treatment)
  • Epilepsy or those who have a history of seizures
  • Poorly controlled Diabetes
  • Current (active) skin cancer within one year or pre-malignant moles in the treatment area. A medical clearance letter is required.
  • Active sores or rash (psoriasis, eczema) in the area to be treated
  • Skin disorder such as keloids or abnormal wound healing
  • History of melanoma, active or inactive anywhere on the body
  • Recent (within 1 months) surgery, laser resurfacing or deep chemical peels in the treatment area
  • Severe medical disorders such as poorly controlled heart conditions
  • Chemo or radiation therapy (letter of clearance from your physician is required)
  • Pacemaker, internal defibrillator, and any internal electrical devices
  • Any internal metal device, i.e. surgical screws, pins, plates, or implants, in the area to be treated (no treatment if any device is superficially in the body area to be treated)
  • Aids, HIV positive or use of immunosuppressive drugs (a letter of clearance from your physician is required)
  • Multiple sclerosis ( a letter of clearance from your physician is required with confirmation that the area to be treated is not numb)
  • Immune disorders such as Scleroderma, Lupus, Porphyria, Sarcoidosis, and others
  • Treatment over moles or lesion of any kind
  • Treatment over tattoos, port wine stains, under the eyebrows, or any orifice
  • Bleeding problems or use of blood thinners
  • History of disease stimulated by heat, such as recurrent Herpes Simplex in the treatment area. You may treat this area only following a prophylactic regime.

 

 

5. Risks and Complications

 

All medical and cosmetic procedures are associated with certain risks and may result in complications. Possible risks and complications associated with laser hair removal procedure include:

  • Temporary reddening, burning, swelling, bruising or discoloration of the skin over the treated area.
  • Blistering, scarring, activation of cold sores, infection or permanent discoloration, which may occur in rare cases. Please inform us if you have ever had a problem with cold sores.
  • Folliculitis, which is an infection of the hair follicle, which may take several days to resolve.
  • Hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin), these changes are often transient and improve with time, although permanent pigmentary changes may occur. 
  • Crusting or blistering of the area exposed to the laser, which is rare and which may take several days to heal.
  • Paradoxical hypertrichosis, induction of terminal hair growth is not common but may occur. 
  • As with all LHR procedures, some re-growth of hair may occur after treatment sessions are completed.

 

 

6. Pre-Procedure Instructions

 

It is IMPORTANT that you follow all pre-treatment and post-treatment instructions carefully to minimize the chances of complications and achieve the optimum results from treatments. 

6 months before:

  • Avoid Accutane 

4 weeks before:

  • Avoid waxing, plucking, using depilatory (hair removal cream) or other hair removal practices.
  • Avoid photosensitive medications (i.e. Anti-biotic, Doxycycline, Tricyclic antidepressants, Quinidine, Amiodarone, St. John Wort etc.) 
  • Avoid other laser treatments/ Microdermabrasion/ Chemical Peels/ Botox/ Filler on the treatment site

2 weeks before:

  • Avoid sun exposure, tanning beds, self tanner such as creams or spray.
  • Avoid skin irritants (i.e. Products contain tretinoin, retinol, benzoyl peroxide, glycolic/salicylic acids, astringents, etc.) 
  • Avoid Anticoagulants

24 hours before:

  • The area to be treated must be CLEAN SHAVED the day before your treatment. 
  • If you have a history of Herpes Simplex Virus or cold sores, you must premeditate one day prior to treatment to prevent further outbreaks.

Day of treatment:

  • Remove any lotions, body oil, perfume, make-up, deodorants and jewelry in the areas to be treated prior to treatment
  • Wear loose fitting clothing that will leave the treatment area exposed and easily accessible for treatment. Tight or rough clothing may cause you to feel uncomfortable if the skin becomes sensitive after treatment.
  • During your treatment you can expect slight discomfort, similar to a rubber-band snap on your skin. If you have sensitive skin, you may apply a topical numbing cream 30 minutes prior to treatment time in order for it to take effect.

 

 

Post-Procedure Instructions

 

Immediately after treatment, there should be erythema (redness) and edema (swelling) at the treatment site which may last 2 hours to several days. The erythema may last up to 2-4 days. The treated area can feel like a sunburn for several hours after.

Rarely, minor epidermal blistering may occur in which case antibiotic ointment may be applied twice a day to the affected areas. DO NOT pick at these areas, as this may result in infection or scarring. If this should happen, please contact our office immediately and our aesthetician will give you further instructions.

TO DO: 

  • It's recommended to apply an ice pack if the treated area is extremely warm and it's not cooling down within 15 minutes.
  • It's recommended to apply Aloe Vera or Hydrocortisone1.5% post-treatment 3 times daily to smooth irritations.
  • For the first 10 days after treatment, your body will push out the dead hairs from follicles. During the shedding phase, hair may look like it's growing, but it is actually shedding out. It’s recommended that you gently exfoliate the treated area 2 to 3 times per week starting from the 2nd week to help the dead hair fall out quicker and easier. Applying moisturizer after exfoliating will help skin replenish. 
  • Apply sunscreen daily. It should be at least SPF 50 protects UVA/UVB and contains the physical blockers zinc oxide and titanium oxide.

 

NOT TO DO: 

  • Avoid any activities that will cause sweating (i.e. exercising, hot shower, hot saunas etc.) for a minimum 12 hours.
  • Avoid skin irritants (i.e. glycolic, acids, retinoids, etc.) for 7 days after treatment.
  • Minimize shaving (try to leave the hairs alone and ONLY shave the day before your next appointment). Excessive shaving may stimulate the hair growth.
  • Avoid plucking, waxing, using a depilatory or undergo electrolysis in between treatments.
  • Avoid sun exposure 2 weeks after laser treatment

 

 

7. Treatment Interval and Follow Up Interval

 

Recommended treatment intervals:

  • Every 4 weeks for facial areas; 
  • Every 6 weeks for body areas; 
  • Every 8 weeks for the legs. 

 

Recommended follow up intervals:

Patient may achieve partial hair clearance or almost complete hair clearance after 6 to 8 sessions. 

  • If there has been partial hair clearance, treatment should be continued between 6 to 8 weeks until optimum result (80-90% hair reduction) is achieved. 
  • Once optimum result is achieved, patients can return for a follow up 3 to 4 months later, or when there is around 15-20% of hair regrowth in the treatment area. 

Please keep in mind, laser hair removal is not exactly permanent as our body will continue to repair the damaged hair follicles and future hormonal changes may stimulate new hair growth, therefore, it's important to follow up after the full initial round of laser treatments to maintain the optimum result.

 

 

By signing below, I certify all information is true and correct to the best of my knowledge:

  • I certify that the information contained in this Informed Consent was explained to me using terms I could understand, and all my questions and concerns have been answered. After reviewing all the information provided to me about cosmetic procedures and reviewing my health status, I believe I am a good candidate for Laser Hair Removal procedure.
  • I understand that I am not allowed to have laser hair removal treatments without a written approval from a parent and/or legal guardian if I am under 18 years old.
  • I understand it's my sole responsibility to inform my technician about any changes in my current medical conditions prior to any of my laser treatments. 
  • I acknowledge and accept the risks inherent in the Laser Hair Removal Procedures. I voluntarily assume the risk of possible complications and side effects which may arise from the Laser Treatments set forth herein; and any of my heirs, executors, representatives or assigns hereby release Bared Monkey Laser Spa and all its affiliated companies from any and all claims, liabilities for personal injury, and property damages of any kind sustained while on the premises, during the treatments set forth herein by any employees or representatives of Bared Monkey Laser Spa and all its affiliated companies.
  • I certify that I have been informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision of to proceed is based solely on my expressed desire to do so. 
  • I certify that I am not pregnant and I am not planning to get pregnant during the course of the treatment.
  • I certify that I have not taken Accutane within the past six months.
  • I certify that I have not taken Anti-biotic within the past four weeks. 
  • I certify that I do not have a pacemaker or internal defibrillator.
  • I confirm that I have read the pre-treatment and post-treatment instructions provided by Bared Monkey Laser Spa and all its affiliated companies and I understand that it's my responsibility to follow these instructions and that my failure to adhere to these recommendations may result in complications and contraindications for which I am fully responsible.
  • I agree to receive text messages and emails from us.appointment confirmation and promotional text message or email will be delivered to the phone number and email on this waiver. You can reply Stop to opt-out text message and/or click on unsubscribed in any email to cancel email communication. 
  • I certify that I have read the entire above Informed Consent and believe the Bared Monkey Laser Spa and all its affiliated companies has adequately explained the risks of this therapy, alternative methods of treatment, and possible benefits from this treatment, and I hereby consent to the laser treatment to be performed by the technicians of Bared Monkey Laser Spa and all its affiliated companies. Considering that I have been informed that certain medical conditions and medications prohibit the patient from laser therapy, I have provided a full and truthful medical history and a truthful and accurate account of my medications to this office. Having been apprised of all the above, I have signed this Consent Form and authorize the subject treatment.

 

March 28, 2024

 

 

 

 

 

 



Please select who will be participating...
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First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Gender
Patient Gender*
First Patient's Signature*
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail. By entering your email, you are agreeing to receive appointment comfirmation, promotional email from us. You can click on unsubscribed to opt-out in any communication emails.
How did you hear about us?
How did you hear about us?*
Friend Referral
Google
Yelp
Online Promotion Sites
Social Media
Others

If you are referred by a friend/family member, please write down his/her name:

Referral Program:

  • Refer ONE friend, get $10 store credits

  • Refer THREE friends, get a FREE lifetime membership

Feel free to check our referral program online for more information. 


Client Intake Form
Please specify your genetic origin:*
African American
Asian- Chinese, Japanese, Korean etc.
Asian- Indian
Caucasian
Hispanic/Latino
Mediterranean
Middle Eastern
American Indian, Alaska Native
Other

Previous Laser Hair Removal Experience:

Have you received any Laser Hair Removal treatment before?*
No
Yes

If "YES", please specify how many sessions conducted in the past and when was the last time?

Treatment Areas Consideration:


Please specify the treatment area(s) for your first visit. *

What other areas you consider in the future?

Prepaid Packages Information:


Please provide a voucher number (You can find the number on your mobile APP)
Patch Test
The patch test is a mini sample for you to gauge what your treatment will be like and how it will feel. A range of settings will be used in the patch test, tailored to your individual skin and hair type, until a good clinical endpoint is achieved. You will be able to feel a slight pinpricking sensation when the desired setting is achieved.The patch test is done two (2) weeks before your first full treatment so that any reactions (i.e. hyper or hypo-pigmentation, blistering etc.) have time to appear and your treatment plan can be adjusted if necessary, to ensure effective results with minimal side effects. A patch test is offered however it does not ensure a client will not have an adverse reaction to subsequent treatments. If waived, I release the technician from liability if I develop an adverse reaction to the laser hair removal treatment. Choose one or the other, not both:*
I waive (skip) the patch test
I consent to (go for) the patch test and I will schedule my first treatment 2 weeks later.
Females Only

You might be contraindicated to Laser Hair Removal if you choose "YES" to any of the following questions, please EMAIL us at care@baredmonkey.com for any assistance: 

Are you pregnant or planning pregnancy during the course of treatment?*
No
Yes
N/A
Are you breastfeeding?*
No
Yes
N/A
For Facial Treatments Only:

You might be contraindicated to Laser Hair Removal if any of the following conditions applied to you, please EMAIL us at care@baredmonkey.com for any assistance: 

Have you had any of the below skin treatments on the face in the last four (4) weeks? *
Chemical Peels
Laser Resurfacing
IPL Facial
Microdermabrasion
Botox/Filler
N/A
Have you had any of the below skin treatments in the treated area(s) in the last two (2) weeks? *
Glycolic Acid, Benzoyl Peroxide or Salicylic Acid
AHA Skin Products
Skin products contains Retin-A, Retinol, Differin, or Tazorac
N/A
Medical History Part I
Do you have any of the following medical conditions? (please check all that apply)
AIDS
Albanism
Active Acne
Bleeding Disorders
Diabetes
Endocrine Disorders
Epidermolysis bullosa
Heart disease
Hemorrhoids
Herpes 1&2
High blood pressure
Gold Theraphy
HIV
Hirsutism
Hormone Replacement
Implants
Kaposi 's sarcoma
Keloid scars
Lesions/Sores/Open wounds
Lupus erythematosus
PCOS
Port-wine stain
Precocious puberty
Psoriasis/Eczema (on the treatment site)
Porphyria
Pacemaker
Rosacea
Seizures/Epliepsy
Skin cancer
Severe histamine reactions
Skin Marks/ Moles/ Freckles
Tattoos/Permanent Makeup (on the treatment site)
Vitiligo
Medical History Part II

You might be contraindicated to Laser Hair Removal if you choose "YES" to any of the following questions, please EMAIL us at care@baredmonkey.com for any assistance: 

Have you taken Accutane in the past six (6) months?*
No
Yes

If "YES", please specify the date of last use.
Have you taken Antibiotics in the past four (4) weeks?*
No
Yes

If "YES", please specify the date of last use.
Have you exposure to sun/artificial tanning or used tanning spray/cream on the treatment area in the last two (2) weeks?*
No
Yes
Have you had any of the below hair removal practices on the treatment areas(s) in the last four (4) weeks?
Waxing
Plucking
Tweezing
Depilatories
Epilating
Electrolysis
Hair Bleaching
Do you have a history of bleeding coagulopathies or use of anticoagulopathies?*
No
Yes
Do you have skin cancer or precancerous lesions?*
No
Yes

If yes, please descript:
Do you have any active skin diseases or infection in the area to be treated?*
No
Yes

If yes, please descript:
Are you undertaking a course of treatment that may make your skin photosensitive?*
No
Yes

If yes, please descript:
Do you have any surgery on the treatment area recently?*
No
Yes

If yes, please descript:

Current Medications:


Please list all medications you have taken during last 4 weeks (if no, please notated "NONE"):

Allergies:


Please list any known allergies: (if no, please notated "NONE"): *
Skin Typing

Please answer the following questions by selecting the number which BEST describes you. 

Eye Color*
0. Light colours
1. Blue, gray or green
2. Hazel/Light Brown
3. Dark Brown
4. Black
Natural Hair Color*
0. Sandy red
1. Blond
2. Chestnut or dark blond
3. Brown
4. Black
Your natural skin color (unexposed area)*
0. Reddish
1. Pale
2. Beige and olive
3. Brown
4. Dark Brown
If you stay in the sun too long?*
0. Painful, redness, blistering and peeling
1. Blistering followed by peeling
2. Burn, mild peeling
3. Rare burn
4. Never had burns
Do you turn brown after several hours of strong sun exposure?*
0. Never
1. Seldom
2. Sometimes
3. Often
4. Always
To what degree do you turn brown?*
0. Hardly or not at all
1. Light color tan
2. Reasonable tan
3. Tan very easily
4. Turn brown quickly
When was your last tan?*
0. +3 months ago
1. 2-3 months ago
2. 1-2 months ago
3. A few weeks ago
4. A few days ago

Reference:
  • Skin Type I: Red or pink undertone, blue/green eyes, blond/red hair, prone to freckles, always burns, never tans.
    Example: Very pale Caucasian, or Albino etc.
  • Skin Type II: Subtle beige undertone, blue or brown eyes, light or dark hair, burns easily, tans minimally.
    Example: Fair-skinned Caucasian etc.
  • Skin Type III: Golden honey tone, green/blue or brown eyes, dark hair, tans after initial burn
    Example: Darker Caucasian, European, Asian, Hispanic etc.
  • Skin Type IV: Olive skin tone, brown eyes, dark hair, burns minimally, tans easily
    Example: Mediterranean, European, Asian, Hispanic, Native American, Middle Eastern etc.
  • Skin Type V: Brown skin tone, brown eyes and dark hair. Rarely burns, tans darkly easily
    Example: Hispanic, Afro-American, Middle Eastern, Asian, African etc.
  • Skin Type VI: Dark brown skin tone, dark brown eyes and black hair. Never burns, always tans darkly
    Example: Afro-American, African, etc.
(* Fitzpatrick, T.B. (1988) The Validity and practicality of sun-reactive skin types I through VI, Arch Dermatol 124; 869-871)


Current and Future Concerns
Please indicate which of the following concerns you have regarding your skin or body?*
Aging
Acne Scar
Spider Veins
Sun Damage
Enlarge Pores
Wrinkles
Hyperpigmentation
Age Spots
Body Contouring/Fat Reduction
None
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Gender
Patient Gender*
Parent or Guardian's Signature*
Electronic Signature Consent*
I certified the information is true and correct. I am aware that it is my responsibility to inform the technicians of Bared Monkey Laser Spa my current medical and health conditions and to update this history is essential for the caregiver to execute the appropriate treatment procedures. I also understand by checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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