Laser Client Form

Health History Skin Consultation & Laser IPL Analysis

Photo Facials and Permanent Hair Reduction
Date

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Area for Hair Reduction you wish to treat?*
Please indicate which services you are interested in?*

Permanent hair ReductionPhoto FacialsDecolletage Sun damageSun Damage HandsDermaplaning FacialMicrodermabrasionMicroneedlingRadio Frequency FacialHydra DermabrasionNot Sure
FITZPATRICK SCORE

Determine your Fitzpatrick Skin Type. PLEASE ADD THE SCORES FROM 1 THROUGH 9 TO GET YOUR FITZPATRICK SCORE:

Following information will help determine the safest treatment for yourself.*


What is the color of your eyes?


Natural color of hair


Skin colour in non exposed areas to sun (Inner arms/belly)


Freckles in non exposed areas to the sun?


Skin reaction if you stay in the sun too long?


To what degree do you turn brown?


Do you turn brown within several hours after sun exposure?


How does your face react to the sun?


When did you last expose your body to the sun or sunbeds?


Did you expose the area to be treated to the sun?

HERE IS WHERE YOU ADD ALL OF THE SCORES TOGETHER FROM 1 TO 9 TO GET YOUR FITZPATRICK SKIN TYPE. Add ALL of the numbers together from the answers above and select your skin type. It is good practice to remember your skin type for future skin treatments.*

0-7 FITZPATRICK SKIN TYPE I: always burns, never tans, pale white, blond or red hair, blue eyes, freckles8-16 FITZPATRICK SKIN TYPE II: usually burns, tans minimally white, fair, blond or red hair, blue, green, or hazel eyes17-25 FITZPATRICK SKIN TYPE III: sometimes mild burn, tans uniformly, cream white, fair with any hair or eye color26-30 FITZPATRICK SKIN TYPE IV: burns minimally, always tans well, moderate brown30 FITZPATRICK SKIN TYPE V-VI: V very rarely burns, tans very easily, dark brown, VI Never burns, never tans, deeply pigmented dark brown to darkest brown
Medical History

Your safety is our first concern please answer to the best of your knowledge
PLEASE CHECK ALL THAT APPLY TO YOUR HEALTH HISTORY*

AcneShinglesCancerHerpes/Cold SoresAny Dermatological ProblemsHirsutismBurnsPsoriasisMelanomaTattoosThyroid Hormone DeficiencyPOS Polycystic Ovarian SyndromeBlood DisordersKeloid FormationHormonal ImbalanceSkin PigmentationHigh Blood PressureDiabetesNon of the Above
Please list any other conditions that you are presently being treated for.
Please list any other medical conditions that you have been treated for in the past.*
If non please mark N/A
Are you currently taking any medications including herbal or vitamins?*
Please label each medication with reason for taking Type N/A if does not apply..
Have taken any medications including herbal or vitamins in the past 6 months or more?*
Please label each medication with reason for taking Type N/A if does not apply.
Please answer the following questions.

Following information will help determine the safest treatment for yourself.*

	YES	NO	N/A
Do you have any allergies, including skin related?
Have you ever used, or are you using Accutane, Retin-A and or Glycolic acid?
Have you ever had a chemical peel?
Have you ever seen a doctor for your skin?
Do you wear sunscreen?
Are you photsensitive?
Do you have any implants?
Have you ever been treated by an Endocrinologist?
Have you ever had any skin resurfacing or photo facials in the past?
Are you planning a holiday in the sun?
Do you currently sunbathe?
Do you use hot water on your face or body?
Are you actively trying to get pregnant?
During pregnancy did you develop masking or hyper pigmentation?
For hair removal hair to be treated is black or dark brown?

Thank you for taking the time to complete this form. For your laser hair removal consulation please ensure the following:
- Please ensure there is hair in area to be treated for me to assess {at least 1/2 inch}
- A patch test will be performed, incase you are finsihing a course of antiobotics please call or message to reschedule consulation for 2 weeks after last dose
- If you have taken the Covid-19 vaccine please wait at least 2 weeks for scheduling laser hair removal consulation {for patch test only as do not want skin to react}
I look forward to meeting you and would love to help you in anyway!
Should be Empty:

Health History Skin Consultation & Laser IPL Analysis

FITZPATRICK SCORE

Medical History

Please answer the following questions.