Patient Medical History Laser Form

Laser Treatment Intake Form
Full Name*

First NameLast Name
Phone/Cell Number*

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
What is your Gender?*

MaleFemale
Check the Skin Type that best describes you?*

Always burns, never tansAlways burns, sometimes tansSometimes burns, always tansRarely burns, always tansBrown, moderately pigmented skinBlack Skin
What is your genetic background?*

Irish ScottishEastern Europe, EnglishWestern EuropeLatino, Middle eastern Hispanic, AsianEast & West IndianAfrican AmericanOther
What Colour are your eyes?*

BlueHazelGreenLight BrownDark BrownDark Brown/BlackOther
Have you Had in the past two weeks?

Laser TreatmentsMicroneedlingBotoxFillersPeelsMicrodermabrasionWaxingOther
Are you currently taking any photosensitive (Eg: Antibiotics) medication?*

YesNo
If so, what medications?
Do you have any known allergies?*

YesNoNot Sure
If yes, what allergies?
Do you or do you have history of keloid scarring?*
Are you currently under the care of a Doctor or Dermatologist?*
If so, Doctor's name?
Have you used any of these products in the past 2 weeks

RetinolGlycolic Peelslactic or salicylic acid products?Sun BurnWaxing, Tweezed or used BleachingMicrodermabrasionLaser ResurfacingChemcial Peels
Please Check any of the following that apply to you?*

Accutane in the past 6 monthsPregnantBreast feedingActive cancerHyper/Hypo pigmentation concernsUse self tanners or tanning bedsSun batherActive psoriasis/exzemaRecent facial surgeryCold soresSkin disease/leisionsHIV/Aids, Hepatitis etcActive infectionSeizure Disorder
Any other health concerns that we should be aware of?
What areas are you interested in for Laser Treatments?

FaceBackUnderarmsScarsBikiniNeckLegsArms/Hands/FeetOtherOther
What type of laser treatments are you interested in?

Hair ReductionSkin ResurfacingPigmentation ConcernsTattoo RemovalVein TreatmentsScarsSkin TagsMicroneedlingOther
Brilliant Bodywork Policies:

It is essential that you arrive 10 minutes prior to your first scheduled appointment. This will allow you enough time to check-in, relax, and update any necessary intake forms. Please note that your scheduled time is your table time. If you arrive late, your session will end as scheduled.

*Please Speak Softly – Brilliant Bodywork is a Quiet Healing Place

*Please Turn Cell Phones Off in Order to Keep Serenity in the Spa

*Please Respect Our Other Guests Right to Solitude

Change/ Cancellation/ No-Show Policy:

Our Therapists are highly trained professionals who are scheduled to serve you based upon the confirmed appointments you make. We kindly request that changes and cancellations be made within 24 hours of the reserved time. A second infraction will result in a cancellation fee of 50% of the total service cost. Individuals who do not show up for a scheduled appointment without a cancellation will be subject to a 100% payment of the scheduled appointment. A credit card guarantee may be required for spa services. Please note that prices and offerings are subject to change without notice. We have been very blessed that this has not been an issue in the past and we thank you for your understanding and business.

a.) I understand that: There is a 24 hours’ notice required for cancellation of an appointment, and that a fee of 50% of the cost of the scheduled service will be charged to me when this courtesy is not provided. I understand that missed appointments without a cancellation will be charged 100% of the service fee.

b.) I understand that: I am to arrive 10 min before my scheduled appointment. This prevents any stress in scheduling to you or the therapists. This also allows you time to use the facilities and relax before your session. You are here to relax and recover.

c.) I understand that: I am to notify my service provider of any changes in my health care or medical history.
I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). I understand I need to sign this waiver prior to every treatment provided, with ANY changes pertaining to the above questionnaire.
Signature

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Laser Treatment Intake Form