Medical History For Laser Treatment

Client Name *

First

Last

Email *

Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Occupation *

Emergency Contact *

Which of the following describes your skin type? *

Do you regularly use tanning salons or sun bathe? *

If yes, how often?

MEDICAL HISTORY

Are you currently under care of a physician? *

If yes, for what?

Are you currently under the care of a dermatologist? *

If yes, for what?

Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation? *

Do you have any of the following medical conditions?

Do you have any other medical conditions?

Please list

Have you ever had an allergic reaction to any of the following?

Please check all that apply and describe the reaction you experienced

Please explain allergic reactions

What oral medications are you presently taking?

Birth control pills
Hormones
Others
None

Please list medications here

Are you currently on any mood altering or anti-depression medication? *

Have you ever used Accutane? *

If yes, when did you last use it?

What topical medications or creams are you currently using?

Retin-A
Others (please list below)
None

Please list topical medications/creams

What herbal supplements do you use regularly?

Have you ever had laser hair removal?

Yes
No

Have you used any of the following hair removal methods in the past six weeks?

Have you recently used any self tanning lotions or treatments? *

Have you recently used any self-tanning lotions or treatments? *

Do you form thick or raised scars from cuts or burns? *

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? *

If yes, please provide details

Are you trying to become pregnant? *

Are you breastfeeding? *

Are you using contraception? *

Submit and Consent to Treatment *

By checking "Submit and Consent to treatment" I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, estetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

MEDICAL HISTORY

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