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/
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YES, I ONLY NEED LASER FOR THE BODY AND NOT THE FACE
Name
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First Name
Last Name
Phone Number
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City/State
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Email Address
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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
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MM/DD/YYYY
How did you hear about us?
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Facebook Ad
Instagram Ad
TikTok
Google Ad
Referral
Radio Ad
Mailer
Other
If you were referred, please place their name here (type N/A if not applicable):
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What area of the body are you interested in being treated? Please select all that apply.
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Upper Lip
Chin
Jawline
Cheeks
Full Face
Full Beard
Under Arm
Brazillian
Bikini
Legs
Arms
Chest/Abdomen
Back
Small areas such as: fingers, knuckles and toes
Your Health
Within the last year, have you been under a dermatologist’s or other physician’s care?
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Please Select
Yes
No
If yes, please specify
List any medications, supplements, vitamins, diuretics, Isotretinoin, etc. that you take regularly:
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Do you have any allergies? Including to food and medicine i.e. Asprin, seafood, apricot, berries, etc.
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Please Select
Yes
No
If yes, please specify
Have you ever had an allergic reaction to aspirin?
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Please Select
Yes
No
Do you sunbathe or use tanning beds?
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Please Select
Yes
No
Do you have metal implants, a pacemaker or facial piercings?
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Yes
No
Your Skin
Have you ever experienced keloids or hypertrophic scars?
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Yes
No
What are your skin goals?
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What are your specific concerns or challenges with your skin? Check all that apply
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General Skin Health
Unwanted hair growth on lip, chin, face, cheeks, jawline, underarms, brazillian, bikini areas.
Acne
Hyperpigmentation (i.e. dark spots, etc.)
Wrinkles
Fine Lines
Pore Size
Oily Skin
Dry Skin
Uneven skin tone
Rosacea
Other
Are you interested in removing any of the following skin irregularities?
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Skin Tags (often mistaken for moles)
Age Spots (often mistaken for freckles)
Sun Spots (often mistaken for freckles)
Milia
Small Spider Capillaries
Cherry Angiomas
Sebaceous Hyperplasia
Fibromas
Cholesterol Deposits
I am not interested or I do not have any of these skin irregularities.
Have you had a chemical peel, microdermabrasion, laser or light therapy, and injectable or other cosmetic procedure in the last month?
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Please Select
Yes
No
Do you use Retin-A, Renova, Adapalene, or any other prescription skin products in the last three months?
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Please Select
Yes
No
Have you taken isotretinoin (Accutane) within the last 6-12 months?
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Please Select
Yes
No
Are you currently using any products that contain the following ingredients? Select all that apply. If yes, please select below.
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Glycolic Acid
Lactic Acid
Exfoliating Scrub
Vitamin A
Other Acid ingredient
I am not using any of these ingredients
Do you use SPF on your skin?
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Please Select
Yes
No
Are you pregnant or trying?
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Please Select
Yes
No
N/A
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I also acknowledge that in order to keep record of my treatment progress photo records are necessary. My esthetician has authorization to take these photos for progress tracking. I also agree that I may be contacted via text about promotional offers and current specials until I OPT-OUT.
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I agree
I have read and agreed to Crystal Ngozi Beauty & Esthetic's policies: https://crystalngozibeauty.com/policies/
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Add any additional notes here:
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