Laser Intake Form

Laser Intake Form
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
What area of the body were you wanting lasered?*
Prior Treatment (if Any)*
SKIN Type*

Always burns, never tansAlways burns, sometimes tansSometimes burns, sometimes tansAlways 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?*
What medications are you taking? (including aspirin)*
Daily consumption of alcohol?*
Allergies*
Heritage (Where are you parents/ grandparents from?)*

HispanicBlackAsianMediterraneanMiddle EasternNative AmericanOther
Do you use chemical sun tanning lotions?*
Should be Empty: