Laser Hair Removal Please fill out the new patient laser assessment and submit the form below. Laser Assessment Form Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * How did you hear about us? * Emergency Contact * Person to contact in case of emergency, Relationship to you, Phone Number: Do you have ANY chronic medical history we should know about? * Yes No If so, please list: Are you under a doctor’s care now? Explain: * Have you ever been treated with hormone medication? * Yes No List present medications, including topical: * List any surgery in the past 6 months: Skin sensitivity to soaps, lotions, hydroquinone or skin bleaching agents? * Allergy to lidocaine or any numbing agents? * Yes No Does your skin get blotchy, red or irritated easily? * Yes No Are you tan in area/s to be treated (from sun, spray on, and/or tanning salon)? * Yes No Past chemical peel? If yes, when? Tattoo or permanent makeup in area/s to be treated? * Yes No Currently pregnant or trying to conceive? * Yes No List any implants: We do not recommend laser therapy if any of the following conditions exist. Please check any box which describes your current health condition. Pregnancy Shingles (active) Photosensitivity disorders Seizure disorders triggered by light Herpes (active) Bacterial infections Have you ever experienced, been treated for or used any of the following? (please check) Accutane Acne Allergies ALS (Amyotrophic Lateral Sclerosis) Anti-Coagulant Birth Control Pill Cancer Cold Sores Diabetes Heart Problems Hemophiliac Hepatitis A,B,C Herpes High Blood Pressure HIV Hysterectomy Irregular Periods Keloid Latex Allergy Menopause Multiple Sclerosis Photosensitizing medication Polycystic Ovaries Pregnancy Psoriasis Retin-A or Alpha Hydroxy Shingles Skin Pigmentation Thyroid Please explain any checked items above: SKIN TYPE: To determine your skin type, please check the one box which best describes your reaction to sun exposure: * Skin Type I - Never tans, always burns (extremely fair skin, blonde/red hair) Skin Type II - Occasionally tans, usually burns (fair skin, sandy to brown hair, green/brown eyes) Skin Type III - Often tans, sometimes burn during first exposure to sun (medium skin, brown hair) Skin Type IV - Always tans, never burns (Olive skin, brown/black hair) Skin Type V - Never burns (dark brown skin, black hair) Skin Type VI - Never burns (black skin, black hair) HAIR REMOVAL: Please list present area/s you are interested in treating. (i.e. facial, back, chest, neck, bikini (regular or Brazilian), underarms, leg tops, leg bottoms, arms, hands, feet, etc.) AND please list desired method/s of hair removal (i.e. laser, waxing, electrolysis) Please list future, possible areas and methods (laser, wax, electrolysis): Previous Hair Removal – Please list area/s, method/s used to remove and approximate date last removed: SKIN REJUVENATION – Laser and Photo Facials (Treat brown spots, wrinkles, melasma, etc.) Please check areas interested in: Face Arms Legs Chest Back Stomach Other Please check and acknowledge the following: * I acknowledge that I am not allergic to lidocaine or any topical numbing agents, to the best of my knowledge. I acknowledge that the information provided on this form is accurate and complete. * Date * MM DD YYYY Thank you!
