New Laser Services Client Intake Form

New Client Laser Intake Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Birthday

MonthDayYear
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?

YesNo
List present medications, including topical.
List any surgeries in past 6 months.
Skin sensitivity to soaps, lotions, hydroquinone, or skin bleaching agents?

YesNoOther
Allergic to Lidocaine or any numbing agents?

YesNo
Does your skin get blotchy, red, or irritated easily?

YesNo
Are you tan in area/s to be treated (from sun, spray on, or tanning salon)?

YesNo
Any tattoo or permanent makeup in area/s to be treated?

YesNo
Currently pregnant or trying to conceive?

YesNo
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.

PregnancyPhoto-sensitivity disordersHerpes (active)Shingles (active)Seizure disorders triggered by lightBacterial infections
Have you ever experienced, been treated for or used any of the following?

AcneAllergiesHerpesCold SoresHemophiliacPolycystic OvariesDiabetesHIVLatex AllergyHepatitis A, B, CHeart ProblemsAnti-CoagulantHigh Blood PressureThyroidHyserectomyMenopauseBirth Control PillPregnancyRetin-A or Alpha HydroxyCancerPsoriasisShinglesSkin PigmentationKeloidAccutanePhoto-sensitizing MedicationMultiple SclerosisALS (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 RemovalWaxingChemical PeelsRadio FrequencyMicroneedelingFacialsOther
Policies

Please Review
Cancellations and Deposits - We try our best to make sure we save a time slot especially for you to give you the full attention you deserve. In order to keep the time available just for you, a $25 NON-REFUNDABLE
deposit is required for all appointments. All deposits will be applied as a credit to the total cost of your service. Please note that all appointment cancellations or reschedules need to take place at least 12 hours in advance of
your scheduled appointment. Failure to provide 12-hour advanced notification will cause forfeiture of deposit.
Refund Policy - We aim to please all of our clients and will do our best to make sure your service is top notch. Therefore, we have a NO REFUNDS policy.
Late Policy - Please arrive 5 minutes before your appointment to settle in and fill out some short paperwork. We know things happen sometimes, so if you are running more than 15 minutes late, please let us know and we
will try to fit you in for a shorter appointment or reschedule you for another time.

I am voluntarily participating in treatment by Mirror Mirror Skin Co LLC and I agree to indemnify and hold harmless against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf.

By signing, client acknowledges the provided information is true to the best of their knowledge and also acknowledges the policies set forth my Mirror Mirror Skin Co.
I hereby acknowledge that I have reviewed and submitted information that is accurate to the best of my knowledge.

Agree
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

New Client Laser Intake Form

Medical Background

Policies