PerfectSkin Aestheticstt
Laser Hair Removal Consultation|Permission Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Dermis Information
Laser Hair Removal
Have you ever had Clinical/professional laser hair removal treatment done?
Yes
No
If yes, please state the type
IPL
Diode laser
Both
What area/areas you will like to be treated
Face
Body
If yes, where and when and was your last treatment.
[ Follow up to above question] Have you completed 5 laser hair removal sessions at pervious Institution ?
YES
NO
If no, please state why.
How do you currently remove your facial or body hairs
Shaving
Waxing
Sugaring
Depilatory Creams
Electrolysis
How often do you remove your hairs
Daily
Weekly
Bi- weekly
Monthly
Is your skin sensitive to any of the above hair removal methods listed above
YES
NO
If yes, please list which hair removal method has a negative reaction to you skin.
Are you currently using any of the following active ingredients on your face or body
Retin A
Roaccutane
Isotretinoin
Tretinoin
Hydroquinone
Differin
Personal Information
Laser Hair Removal
Do you have any allergies or intolerance?
Yes
No
Are currently or possibly pregnant
Yes
No
Are you currently on any medication prescribed by a doctor?
Yes
No
Do you experience cold sores?
Yes
No
Are you being treated for any of the following medical conditions
Cancer
HIV/AIDS
SKIN CANCER
Bleeding Disorder
Hormonal imbalance
Hirsutism
Signature
Do you give permission to receive laser hair removal treatments at PerfectSkin
Yes
No
Should be Empty: