Client Consent Form

Client Consent Form
Client's Name

First NameLast Name
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Occupation
How did you hear about us?

FacebookInstagramGoogle searchReferralOther
If referred, by who? Please write first and last name
Your Medical History
Do you have any of the following conditions? If yes, please select all that apply:

CancerHypertensionHypotensionMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsCancerRemissionOther
Skin condition

OilyDryAcneOther
How does your skin heal?

FastPigmentsScarsSlowOther
What is the main concern of your visit?
Do you consume alcohol?

NoOcassionally2-3 times a week
Are you pregnant or breastfeeding ?

NoPregnantBreastfeedingTrying to conceive
Are you taking any contraceptive pills?

YesNo
Do you currently use Accutane, Retin-A or a prescribed topical cream?

YesNo
If yes, please specify below
Have you ever been diagnosed with any of the following

RosaceaPsoriasisEczemaOther
Are you taking any antibiotics? If yes, please specify below
Are you currently under any kind of diet?

YesNo
Any know allergies?

LatexFruitsPollenShellfishLidocaineTree nutDairySunscreenPollenNoneOther
Please rate your stress level

LowMediumHighNone
Are you prone to keloid or hypertrophic scarring?

YesNo
Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. Thisinformation will help your technician determine the most appropriate way to approach your treatment(s):

Fitz 1 - extremely sensitive, always burns, never tansFitz 2 -very sensitive, burns easily, tans with difficultyFitz 3 - sometimes burns, slowly tansFitz 4 - burns minimally , tans with ease to moderate brownFitz 5 - rarely burn, tans easilyFitz 6 - Never burns, deeply pigmented
Does your job require you to be outdoors ?

YesNo
Have you ever received any botox or fillers? if so, what area and when? Please give an approximate or exact date
Have you self tanned, spray tanned or used a tanning bed recently? Please know you need to allow at least two weeks for the self tanner, tan or spray tan to go away.

YesNo
What beauty or cosmetic products are you currently using?
Terms & Conditions
I understand that my data will be strictly confidential. I confirm that all information in this form is true and accurate. I confirm that if I withhold important information and complications happened, Aesthetic Laser Studio LLC will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

PLEASE READ -

Aesthetic Laser Studio charges a 25% cancellation fee for any no-show or cancellations if less than a 24hr notice of scheduled appointment. If you have a package with the facility then your treatment will be deducted from your package. NO EXCEPTIONS! We value all our clients and will try to accommodate to the best of our ability.

Should your card decline, you will be required to pay the cancellation fee on your following appointment. Aesthetic Laser Studio can refuse service at any time and you will no longer be able to book future appointments.

All treatments, services and products are non- refundable.
Client Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Client Consent Form

Your Medical History

Terms & Conditions