AEROLASE

AEROLASE

NEO ELITE
Patient Intake form
Date*

MonthDayYear
Date
Patient/Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Approval to send you information regarding aesthetic promotions, products, and services? (Yes or No)
Referred by
Primary Concerns for today's treatment
Secondary Concern for today's treatment
Allergies*
Have you addressed your concerns with a physician or aesthetician prior to today’s treatment? ( Yes or No, Explain)
Indicate the following concerns (Select all that apply)

Melasma/Pigmentation/ HyperpigmentationAge / Sun Spots / Brown SpotsNeck & Chest DiscolorationBroken Blood VesselsRed Spots/ FlushingRosacea/ RednessActive AcneFacial OilinessFacial DrynessFacial Volume LossCrows FeetForehead Lines / Frown Lines / Lip LinesLip Volume LossNose-to-Mouth LinesUnder Eye CirclesScarringSkin Texture/Skin TextureUnwanted HairSpider VeinsTone, Texture, TighteningTech Neck
Do you know anyone else with these skin concerns? (Provide name and number)
Please indicate the following services of interest to you (please check all that apply)

BOTOX CosmeticsChemical PeelsCosmetic Facial TreatmentsCosmetic Laser TreatmentsFacial injectables/Dermal FillersGeneral Skin HealthProduct AdviceMicrodermabrasionSPF AdviceOther
When was the last time you received cosmetic consult or facial service:

MonthDayYear
Date
Type of service received (Select all that apply)

BOTOX CosmeticsChemical PeelsDermal FillerFacialLaser TreatmentWaxingOther
Have you ever been on Accutane?

YesNo
Are you pregnant or lactating (breastfeeding)?

YesNo
Do you have a history of herpes simplex (cold sores)?

YesNo
Do you currently take an anti-viral medication for the prevention or treatment of cold sores?

YesNo
Do you have a history of lupus or any other auto-immune disease?

YesNo
Have you ever developed keloids (raised scars)?

YesNo
Do you tan on a regular basis?

YesNo
Do you have a history of atypical moles, Melanoma or skin cancer in your family?

YesNo
Please describe your current skin care regimen:
Please describe any adverse reactions to topical skin care products, makeup, and medications:
Weekly at-home facial treatments: Masks / Scrubs / Other. Please list:
Please describe your current skin care regimen:
Morning Cleanserblanks .
Morning Toner/Treatment Products:blank.
Evening Cleanserblanks .
Evening Toner/Treatment Products:blank.
Morning Prescriptions/Treatment Productsblanks .
Morning Prevention/Serum Products:blank.
Evening Prescriptions/Treatment Productsblanks .
Evening Prevention/Serum Products:blank.
Morning Moisturizer/Creams:blanks .
Morning SPFblank.
Evening Moisturizer/Creams:blanks .
Evening SPFblank.
Do you feel your current skin care regimen is addressing your primary and secondary concern? (Yes or No and Explain)
Does your skin ever flake or feel tight and dry? (Yes or No, Explain)
Do you feel oily a few hours after cleansing? (Yes or No, Explain)
INFORMED CONSENT FOR Nd:YAG 1064NM LASER PROCEDURES
I,(full name) blanks , have given Issa Selflove Oasis and its entities permission to perform Nd:YAG laser procedures on myblank (treatment area).
The LightPod Neo® (Nd:YAG 1064nm) laser is FDA approved for a variety of procedures including hair removal, vein treatment and wrinkle reduction. This form is designed to give you the information you need to make an informed choice of whether or not to undergo Nd:YAG laser treatment. If you have any questions, please do not hesitate to ask. Although the laser treatment is effective in most cases, no guarantee can be made that a specific patient will benefit from the treatment.

The laser emits an intense beam of light that is absorbed in specific body tissues within the skin, and depending upon the type of procedure, several treatments may be required at intervals specified by the physician.

Some of the possible complications of Nd:YAG laser treatment are:
Discomfort – The procedure is done so precisely that surrounding tissue is minimally affected; the patient may experience a mild sensation of pain in the treated areas. Some degree of skin flushing may occur, but it typically resolves within several hours. *
Initials
Scarring – There is a small chance of scarring, including hypertrophic scars, or very rarely, keloid scars. Keloid scars are very heavy raised scar formations. To minimize chances of scarring, it is important that you follow all postoperative instructions carefully. It is important that any prior history of unfavorable healing be reported. *
Initials
Pigmented changes – The treated area may heal with lighter or darker pigmentation. This occurs more often in darker pigmented skin and following exposure of the area to the sun. It is recommended that you protect yourself from any sun exposure for at least three months following treatment. Hyperpigmentation usually fades in three to six months. However, pigment change can be permanent.*
Initials
HSV Reactivation – The patient agrees to notify the physician if he/she has any history of Herpes viral infections, as the laser procedure may cause it to reactivate.*
Initials
Lack of Treatment Response – There is a possibility that the targeted hairs, veins or other treated areas will not respond to the treatment. This is often a function of the specific body chemistry of the patient, including relative pigmentation and light absorption characteristics of the patient’s various body tissues*
Initials
Lack of Treatment Response – There is a possibility that the targeted hairs, veins or other treated areas will not respond to the treatment. This is often a function of the specific body chemistry of the patient, including relative pigmentation and light absorption characteristics of the patient’s various body tissues*
Initials
Eye Exposure – There is also the risk of harmful eye exposure to laser surgery. Safeguards should be provided by the laser practitioner. It is important that you keep your eyes closed and have protective eye wear at all times during the laser treatment.*
Initials
Photographs – I consent to be photographed before, during, and after the treatment and that these photographs shall be the property of the above practitioner or owner and may be published in scientific journals or for scientific or marketing reasons.*
Initials
I certify that I have read or have had read to me, the content of this form. I understand the risks and alternatives involved in this procedure. I have had the opportunity to ask all possible questions and all of my questions have been answered. I also have been given the chance to refuse treatment and once I have signed, I am giving consent to move forward with all treatments provided to me by Issa Selflove Oasis and their entities.
Date*

MonthDayYear
Date
Patient/Client or Parent/Guardian Name (if under 18 years old)*

First NameLast Name
Relationship to Patient/Client (Self, Parent, Guardian, etc.)*
Patient Signature*

Clear
Witness

First NameLast Name
Witness Signature

Clear
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AEROLASE

Patient Intake form