AEROLASE

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.Format: (000) 000-0000.

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)

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)

When was the last time you received cosmetic consult or facial service:

Date

Type of service received (Select all that apply)

Have you ever been on Accutane?

Are you pregnant or lactating (breastfeeding)?

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

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

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

Have you ever developed keloids (raised scars)?

Do you tan on a regular basis?

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

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

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

First NameLast Name

Relationship to Patient/Client (Self, Parent, Guardian, etc.)

Patient Signature

Witness

First NameLast Name

Witness Signature

AEROLASE

Patient Intake form