Laser Intake Form
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What area of the body were you wanting lasered?
*
Prior Treatment (if Any)
*
SKIN Type
*
Always burns, never tans
Always burns, sometimes tans
Sometimes burns, sometimes tans
Always tans
History of skin cancer or pre-cancerous lesions. (if yes explain)
*
Any active infection (if yes explain)
*
Disease which may be stimulated by light at 515nm to 1200nm, such as a history of Herpes Simplex, Cold Sores, Systemic Lupus Erythematosus, or Porphyria (if yes please explain)
*
Use of photosensitive medication and/or herbs that may cause sensitivity to light such as isotretinoin, tetracycline, or St Johns Worth. (if yes Please Explain)
*
Immunosuppressive disease, including AIDS and HIV infection, or use of immunosuppressive medication. (if yes explain)
*
History of diabetes?
*
History of bleeding disorders or use of anticoagulants. (if yes please explain)
*
History of keloid scarring? Family history of keloids.
*
History of hidradenitis suppurativa?
*
Exposure to sun or artificial tanning during 3-4 weeks prior to treatment.
*
Are you pregnant?
*
Please Select
Yes
No
What medications or supplements are you taking? (including aspirin)
*
Daily consumption of alcohol?
*
Allergies
*
Heritage (Where are you parents/ grandparents from?)
*
Hispanic
Black
Asian
Mediterranean
Middle Eastern
Native American
Other
Do you use chemical sun tanning lotions?
*
Please Select
YES
NO
If you pluck or wax, when was the last time? You must wait 1 month for treatment after plucking or waking.
Type your name to acknowledge the appointment policy- if you do not cancel your appointment 24 hours in advance you will be charged the amount of that visit or an appointment will be taken from your purchased package if applicable.
Submit
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