Laser Hair Removal Intake Form
Name
*
First Name
Last Name
Date
-
Month
-
Day
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
First Name
Last Name
Emergency Contact
Please enter a valid phone number.
Format: (000) 000-0000.
I acknowledge that laser hair removal at Revive Glam Studio is a medical procedure performed by a licensed esthetician and certified laser technician under licensed medical supervision and delegated authority. Treatment Parameters are selected based on medical protocols, skin type, skin tone, and hair characteristics.
I acknowledge medical oversight and wish to proceed with treatment.
Please select all that apply:
Pregnancy or Breastfeeding
Photosensitive Medications
Isotretinoin (Accutane) within the past 12 months
Active Infection, Rash Lesion in the treatment area
History of Keloid scarring
Autoimmune disorder
Hormonal Disorder (PCOS, thyroid, etc)
None of the above
Other
Current Medications (including prescriptions, over-the-counter, and supplements)
Do any of your medications cause you to be photosensitive??
Known Allergies (medications, skincare products, etc.)
Are you currently pregnant or breastfeeding? (Yes/No)
Do you have any of the following conditions? (Check all that apply)
Diabetes
Epilepsy or seizures
Skin conditions (eczema, psoriasis)
History of keloid scarring
Autoimmune disorders
Herpes simplex virus (cold sores)
Blood disorders (hemophilia, anemia)
Cancer (current or past)
Other medical conditions (please specify)
Current Hair Color in Treatment Area:
Please note white or gray hair will not be targeted by the laser.
Have you used any tanning beds or sunless tanner in the past 4 weeks? (Yes/No)
Have you had any recent sunburns in the treatment area? (Yes/No)
Do you have a history of hyperpigmentation or hypopigmentation? (Yes/No)
Previous Laser Hair Removal Treatments? (Yes/No, if yes, specify details)
List any active skincare products used (retinoids, glycolic acid, etc.):
Do you use any skin-lightening products? (Yes/No)
Have you had any cosmetic treatments (chemical peels, microdermabrasion) in the past month? (Yes/No)
Treatment Area(s) Requested: (Please include future areas)
Do you smoke or consume alcohol regularly? (Yes/No)
Are you currently taking any blood-thinning medications (e.g., aspirin, warfarin)? (Yes/No)
Do you have a history of cold sores (herpes simplex)? (Yes/No)
Please Select The Option That Best Applies to your skin tone and skin reaction to the sun.
I (Very fair, always burns, never tans)Nicole Kidman, Emma Stone
II (Fair, usually burns, tans minimally)Cate Blanchett, Amanda Seyfried
III (Medium, sometimes burns, gradually tans)Jennifer Aniston, Anne Hathaway
IV (Olive, rarely burns, tans easily)Penélope Cruz, Eva Mendes
V (Brown, very rarely burns, tans very easily)Rihanna, Mindy Kaling
VI (Dark brown, never burns)Lupita Nyong’o, Idris Elba
Consent and Acknowledgment:I understand the potential risks and benefits of laser hair removal, including the possibility of temporary redness, swelling, tenderness, burns, blistering, scarring, hyper/hypopigmentation, and paradoxical hair growth. I confirm that the information provided above is accurate to the best of my knowledge.I agree to follow all pre- and post-treatment care instructions provided by my service provider.
*
Yes
No
Laser hair removal requires multiple sessions. Results vary by individual and are not guaranteed. Permanent hair reduction is expected, not complete hair removal.
*
I acknowledge and understand the expectations of laser hair removal
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First Name
Last Name
Date
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