• LASER INTAKE FORMS

    LASER INTAKE FORMS

  • Personal Information

  • Format: (000) 000-0000.
  • Date of birth
     / /
  • Gender
  • Format: (000) 000-0000.
  • Skin Type Assessment

  • Fitzpatrick Skin Type
  • Self-Tanning Lotion*
  • Hair Assessment

  • Hair density
  • Hair Thickness
  • Medical History*
  • I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment.

    I understand that there is a possibility of short-term effects such as:

    PAIN & DISCOMFORT - The level of pain and discomfort varies with a person’s tolerance, and both may be experienced during treatment.

    BURNS - Laser energy can produce burns. Adjacent structures including the eyes may be injured or permanently damaged by the laser beam. Burns are rare yet represent the effect of heat produced within the tissues by laser energy. Additional treatment may be necessary to treat laser burns.

    REDNESS & SWELLING - Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. An urticarial (hive-like) reaction may occur as well.

    PURPURA/BRUISING - Purpura (bruising) is a transient phenomenon that usually resolves with time.

    HEMOSIDERIN STAINING - (Iron leaking into tissue from blood breakdown) may occur and usually resolves over time, but it may be permanent.

    SKIN SENSITIVITY - Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur. This typically resolves during the healing process, but in rare situations it may be chronic.

    WOUND HEALING - Treatment can result in burning, blistering, or bleeding of the treated areas resulting in a wound. If this occurs, please contact our office.

    INFECTION - Infection is a possibility whenever the skin surface is disrupted, though proper wound care should prevent this. If signs of an infection develop, such as pain, heat or surrounding redness, please contact our office at (832)384-4608

    Herpes simplex virus infections (cold sores) around the mouth can occur/ reoccur following a laser treatment. This applies to both individuals with a history of Herpes simplex virus infections and individuals with no known history of Herpes simplex virus infections in the mouth area. If you had cold sores in the past, please let your provider know as specific medications can be prescribed and taken both prior to and following the procedure to suppress an infection from this virus.

  • I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment.

    I understand that there is a possibility of short-term effects such as:

    PAIN & DISCOMFORT - The level of pain and discomfort varies with a person’s tolerance, and both may be experienced during treatment.

    BURNS - Laser energy can produce burns. Adjacent structures including the eyes may be injured or permanently damaged by the laser beam. Burns are rare yet represent the effect of heat produced within the tissues by laser energy. Additional treatment may be necessary to treat laser burns.

    REDNESS & SWELLING - Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. An urticarial (hive-like) reaction may occur as well.

    PURPURA/BRUISING - Purpura (bruising) is a transient phenomenon that usually resolves with time.

    HEMOSIDERIN STAINING - (Iron leaking into tissue from blood breakdown) may occur and usually resolves over time, but it may be permanent.

    SKIN SENSITIVITY - Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur. This typically resolves during the healing process, but in rare situations it may be chronic.

    WOUND HEALING - Treatment can result in burning, blistering, or bleeding of the treated areas resulting in a wound. If this occurs, please contact our office.

    INFECTION - Infection is a possibility whenever the skin surface is disrupted, though proper wound care should prevent this. If signs of an infection develop, such as pain, heat or surrounding redness, please contact our office at (832)384-4608

    Herpes simplex virus infections (cold sores) around the mouth can occur/ reoccur following a laser treatment. This applies to both individuals with a history of Herpes simplex virus infections and individuals with no known history of Herpes simplex virus infections in the mouth area. If you had cold sores in the past, please let your provider know as specific medications can be prescribed and taken both prior to and following the procedure to suppress an infection from this virus.

  • Additional Advisories

  • I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment.

    I understand that there is a possibility of short-term effects such as:

    PAIN & DISCOMFORT - The level of pain and discomfort varies with a person’s tolerance, and both may be experienced during treatment.

    BURNS - Laser energy can produce burns. Adjacent structures including the eyes may be injured or permanently damaged by the laser beam. Burns are rare yet represent the effect of heat produced within the tissues by laser energy. Additional treatment may be necessary to treat laser burns.

    REDNESS & SWELLING - Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. An urticarial (hive-like) reaction may occur as well.

    PURPURA/BRUISING - Purpura (bruising) is a transient phenomenon that usually resolves with time.

    HEMOSIDERIN STAINING - (Iron leaking into tissue from blood breakdown) may occur and usually resolves over time, but it may be permanent.

    SKIN SENSITIVITY - Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur. This typically resolves during the healing process, but in rare situations it may be chronic.

    WOUND HEALING - Treatment can result in burning, blistering, or bleeding of the treated areas resulting in a wound. If this occurs, please contact our office.

    INFECTION - Infection is a possibility whenever the skin surface is disrupted, though proper wound care should prevent this. If signs of an infection develop, such as pain, heat or surrounding redness, please contact our office at (832)384-4608

    Herpes simplex virus infections (cold sores) around the mouth can occur/ reoccur following a laser treatment. This applies to both individuals with a history of Herpes simplex virus infections and individuals with no known history of Herpes simplex virus infections in the mouth area. If you had cold sores in the past, please let your provider know as specific medications can be prescribed and taken both prior to and following the procedure to suppress an infection from this virus.

  • Do you authorize Camellia Alise, LLC and its representatives to photograph or record you for educational, promotional, advertising, publication, or trade purposes, and release the company from any related claims or liability?*
  • TRAVEL PLANS - Any treatment holds the risk of complications that may delay healing and delay your return to normal life. Please let the treatment provider know of any travel plans, important commitments already scheduled or planned, or time demands that are important to you, so that appropriate timing of your treatment can occur. There are no guarantees that you will be able to resume all activities in the desired time frame.

    SKIN CANCER/SKIN DISORDERS - Skin treatment procedures do not offer protection against developing skin cancer or skin disorders in the future.

    BODY PIERCINGS - Individuals who currently wear body-piercing jewelry in the treated region are advised that an infection could develop from this activity.

    MENTAL HEALTH DI SORDERS AND ELECTIVE PROCEDURES - It is important that all patients seeking to undergo elective treatments have realistic expectations that focus on improvement rather than perfection. Complications or less than satisfactory results are sometimes unavoidable, may require additional treatments, and can be stressful. Please openly discuss with your treatment provider, prior to the treatment, any history that you may have of significant emotional distress or mental health disorders. Although many individuals may benefit psychologically from the results of elective procedures, effects on mental health cannot be accurately predicted.

  • Date*
     / /
  • Date*
     / /
  • ALLERGIC REACTIONS - In some cases, local allergies to products used during or after treatment such as adhesive, numbing agents, topical preparations and topical post-care have been reported. Systemic reactions which are more serious may occur to drugs used during the procedure. Allergic reactions may require additional treatment.

    EYE EXPOSURE - Eye injury is possible from laser procedures. Protective eyewear (shields or goggles) will be provided. It is important to keep these on always during the treatment to protect your eyes from injury.

    SUN EXPOSURE/ TANNING BEDS/ ARTIFICIAL TANNING - May increase risk of side effects and adverse events. It has been advised that you discontinue and avoid UV exposure and artificial tanning before, during, and after your treatment and recommended that you discontinue this practice all together as the effects of the sun are damaging to the skin. A broad spectrum (UVA/UVB) sunscreen should be used to prevent further pigmentation. Exposing the treated areas to sun may result in increased scarring, color changes, and poor healing. Patients who tan, either outdoors or in a salon, should inform their treatment provider and either delay their treatment or avoid UV exposure until your provider says it is safe to resume. The damaging effects of UV exposure occurs even with the use of sunscreen or clothing coverage.

    TREATMENTS - The number of treatments vary but multiple treatments are always required. The number of treatments needed to clear your pigmented lesion is unknown.

    LACK OF PERMANENT RESULTS - Skin treatments may not completely improve or prevent future skin disorders, lesions, or wrinkles. No technique can reverse the signs of skin aging. Additional treatments may be necessary to further improve your skin. You may be required to continue with a skin care maintenance program after a treatment.

    OTHER - You may be disappointed with the results of your treatment. Infrequently, it is necessary to perform additional treatments to improve your results.

    UNKNOWN RISKS - There is the possibility that additional risk factors of treatment may be discovered.

  • Laser Treatment Health & Liability Acknowledgment

  • ALLERGIC REACTIONS - In some cases, local allergies to products used during or after treatment such as adhesive, numbing agents, topical preparations and topical post-care have been reported. Systemic reactions which are more serious may occur to drugs used during the procedure. Allergic reactions may require additional treatment.

    EYE EXPOSURE - Eye injury is possible from laser procedures. Protective eyewear (shields or goggles) will be provided. It is important to keep these on always during the treatment to protect your eyes from injury.

    SUN EXPOSURE/ TANNING BEDS/ ARTIFICIAL TANNING - May increase risk of side effects and adverse events. It has been advised that you discontinue and avoid UV exposure and artificial tanning before, during, and after your treatment and recommended that you discontinue this practice all together as the effects of the sun are damaging to the skin. A broad spectrum (UVA/UVB) sunscreen should be used to prevent further pigmentation. Exposing the treated areas to sun may result in increased scarring, color changes, and poor healing. Patients who tan, either outdoors or in a salon, should inform their treatment provider and either delay their treatment or avoid UV exposure until your provider says it is safe to resume. The damaging effects of UV exposure occurs even with the use of sunscreen or clothing coverage.

    TREATMENTS - The number of treatments vary but multiple treatments are always required. The number of treatments needed to clear your pigmented lesion is unknown.

    LACK OF PERMANENT RESULTS - Skin treatments may not completely improve or prevent future skin disorders, lesions, or wrinkles. No technique can reverse the signs of skin aging. Additional treatments may be necessary to further improve your skin. You may be required to continue with a skin care maintenance program after a treatment.

    OTHER - You may be disappointed with the results of your treatment. Infrequently, it is necessary to perform additional treatments to improve your results.

    UNKNOWN RISKS - There is the possibility that additional risk factors of treatment may be discovered.

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