BODY Laser Hair Removal Consultation Form (BODY ONLY)

BODY Laser Hair Removal Consultation Form (BODY ONLY)

Please note that if you desire to have a consultation for Laser Hair Removal on the Face, please complete our Skincare Form: https://crystalngozibeauty.com/
Please note that if you desire to have a consultation for Laser Hair Removal on the Face, please complete our Skincare Form: https://crystalngozibeauty.com/
Name

First NameLast Name
What is your preferred pronoun?
If Other, please specify
Phone Number
City/State
Email Address
I will be following up with you on how to begin via email so please use the address you check most frequently! I will never sell your email or spam.
Date of Birth
MM/DD/YYYY
How did you hear about us?

Other
If you were referred, please place their name here (type N/A if not applicable):
What area of the body are you interested in being treated? Please select all that apply.
Your Health
Within the last year, have you been under a dermatologist’s or other physician’s care?
If yes, please specify
List any medications, supplements, vitamins, diuretics, Isotretinoin, etc. that you take regularly:
Do you have any allergies? Including to food and medicine i.e. Asprin, seafood, apricot, berries, etc.
If yes, please specify
Have you ever had an allergic reaction to aspirin?
Do you sunbathe or use tanning beds?
Do you have metal implants, a pacemaker or facial piercings?
Your Skin
Have you ever experienced keloids or hypertrophic scars?
What are your skin goals?
What are your specific concerns or challenges with your skin? Check all that apply

Other
Are you interested in removing any of the following skin irregularities?
Have you had a chemical peel, microdermabrasion, laser or light therapy, and injectable or other cosmetic procedure in the last month?
Do you use Retin-A, Renova, Adapalene, or any other prescription skin products in the last three months?
Have you taken isotretinoin (Accutane) within the last 6-12 months?
Are you currently using any products that contain the following ingredients? Select all that apply. If yes, please select below.
Do you use SPF on your skin?
Are you pregnant or trying?
I confirm that the information I have provided is accurate and complete. I understand that withholding relevant information may affect my treatment results, and I will not hold my Esthetician responsible for any adverse reactions. I consent to Crystal Ngozi Beauty & Esthetics using my skin photos to track my progress and for internal research and service development. All images will be kept anonymous and will never be used for marketing without separate permission. By checking ‘I agree,’ I acknowledge and accept all terms.
I have read and agreed to Crystal Ngozi Beauty & Esthetic's policies: https://crystalngozibeauty.com/policies/
Add any additional notes here:
Signature
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BODY Laser Hair Removal Consultation Form (BODY ONLY)

Your Health

Your Skin