Alite Laser Hair Removal and Skin Rejuvenation

Alite Laser Hair Removal and Skin Rejuvenation

Client Registration and Health Assessment Form
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Birthday

Month Day Year
Date
Occupation
How did you hear about us?
Medical Background
Do you have any chronic medical history we should know about? If yes, explain
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 surgeries in past 6 months.
Skin sensitivity to soaps, lotions, hydroquinone, or skin bleaching agents?

Yes No
Allergic 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, or tanning salon)?

Yes No
Any 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 Photo-sensitivity disorders Herpes (active) Shingles (active) Seizure disorders triggered by light Bacterial infections
Have you ever experienced, been treated for or used any of the following?

Acne Allergies Herpes Cold Sores Hemophiliac Polycystic Ovaries Diabetes HIV Latex Allergy Hepatitis A, B, C Heart Problems Anti-Coagulant High Blood Pressure Thyroid Hyserectomy Menopause Birth Control Pill Pregnancy Retin-A or Alpha Hydroxy Cancer Psoriasis Shingles Skin Pigmentation Keloid Accutane Photo-sensitizing Medication Multiple Sclerosis ALS (Amyotropic Lateral Sclerosis
Skin Type: To determine your skin type, please choose which describes your reaction to sun exposure.

Skin Type 1 - Never tans. always burns (extremely fair skin, blonde, red hair) Skin Type 2 - Occasionally tans, usually burns (fair skin, sandy to brown hair) Skin Type 3 - Often tans, sometimes burns during first exposure to sun (medium skin, brown hair) Skin Type 4 - Always tans, never burns (olive skin, brown/black hair) Skin Type 5 - Never burns (dark brown skin, black hair) skin Type 6 - Never burns ( black skin, black hair)
What services are you interested in?

Laser Hair Removal Waxing Electrolysis Skin Rejuvenation Cellulite Reduction Microblading
I aknowledge that the information provided on this form is accurate and complete:
Signature

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Date

Month Day Year
Date

Cancellation Policy
At Alite Laser, every appointment scheduled has a specific time allotted dependent on client needs. Because our Technicians work strictly on commission, if you no-show or cancel without giving 24-hour notice, they do not have the adequate time needed to fill their schedule with another appointment. Please keep this in mind should you need to change or cancel an appointment.

24-hour notice is required for any cancellation/rescheduling of an appointment. The fee for any missed appointment is $25 and will be charged prior to rescheduling.

Any client with three no-shows or cancellations within the same year will be required to prepay $25 to hold any future appointment. The $25 holding fee will be credited to that treatment or will be forfeited should you not make the appointment.

If you're later than 15 minutes to your appointment, we may have to reschedule, and this will count as a same-day cancellation. Please give us a warning if you're going to be more than 5 minutes late.

Due to the extremely high Saturday cancellation rates, we require clients to prepay $25 to hold an appointment. This deposit may be applied to your appointment, or will be forfeited should you cancel the appointment with less than 24-hour notice.

Wax clients: There will be a $10 cancellation fee.

You can call or text us at (512) 328-1555 or contact us via email at admin@alitelaser.com and/or info@alitelaser.com

Thank you for your loyalty, we value you as a client and appreciate you valuing our time as well.
I hereby acknowledge that I have reviewed and agree to Alite Laser's cancellation policy.

Agree
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Precautionary Coronavirus Liability Release Form
Due to the 2020 outbreak of the novel Coronavirus (COVID-19) we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfection practices. Please review and agree to the following before your appointment.

Symptoms of COVID-19 include:
- Cough
- Shortness of breath/difficulty of breathing
- Headache
- Sore throat
- Loss of taste or smell
- Diarrhea
- Body aches/pain
- Fatigue
- Chills or shaking with chills
- Feeling feverish or a temperature greater or equal to 100.0 degrees
I understand the above symptoms and affirm that I, as well as all household members do not currently have the symptoms listed above within the last 14 days.

Yes
I affirm that I, as well as all household members, have not been diagnosed with or knowingly been exposed to anyone diagnosed with COVID-19 within the last 14 days.

Yes
By signing I agree to each above statement and release the technician and business from any and all liability for the unintentional exposure or harm due to COVID-19 and other communicable conditions.
Signature

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Name

First Name Last Name
Date

Month Day Year
Date
Should be Empty:

Alite Laser Hair Removal and Skin Rejuvenation

Medical Background

Cancellation Policy

Precautionary Coronavirus Liability Release Form