Laser & Light-Based Treatment Intake Form

Laser & Light-Based Treatment Intake Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Information

Laser and light-based treatments (Laser Hair Removal, IPL, Pico Laser) use targeted energy to treat hair follicles, pigmentation, vascular lesions, tattoos, and for overall skin rejuvenation. Multiple sessions are typically required for best results.
Contraindications

(You must inform your provider if any apply to you)
Please check all that apply. Laser and light-based treatments may NOT be performed if you have/are:

Pregnant or breastfeedingRecent tanning, sunburn, or spray tan (within 2–4 weeks)Use of Accutane (isotretinoin) within the past 6–12 monthsUse of photosensitizing medications (e.g., certain antibiotics, antifungals, acne meds)History of keloid scarring or abnormal wound healingActive infection, open wounds, rashes, cold sores, or eczema/psoriasis in the treatment areaActive skin cancer or suspicious lesions in the treatment areaEpilepsy triggered by lightUncontrolled diabetes or bleeding disordersUse of blood thinners (unless cleared by a physician)Recent chemical peel, microneedling, or other resurfacing treatment (within 2 weeks)Metal implants, pacemaker, or medical devices in/near treatment area (for some devices)
Client Initials (acknowledging review): Initials*
Pre-Treatment Acknowledgment (Applies to All Laser Treatments)
I confirm that:*

I have disclosed my full medical history (medications, allergies, conditions, recent procedures).I am not pregnant or breastfeeding.I have avoided tanning beds, self-tanners, and direct sun exposure for at least 2 weeks before treatment.I have followed all pre-treatment instructions provided by my practitioner.
Risks (All Treatments)

I understand that while rare, possible risks include:
- Redness, swelling, tenderness, itching
- Blistering, burns, scarring, or infection
- Hyperpigmentation (darkening) or hypopigmentation (lightening)
- Incomplete or variable results
Treatment-Specific Information

Laser Hair Removal
- Targets hair follicles to reduce future growth.
- Works best on darker hair; lighter hair may respond poorly.
- Requires multiple sessions (average 6 to 12 treatments).
- Hair shedding occurs gradually.
- Regrowth can also depend on factors such as hormonal activity
Client Initials (acknowledging review): Initials*
IPL Skin Treatments
- Uses broad-spectrum light to target pigmentation, redness, and stimulate collagen.
- Treated spots may darken before flaking off.
- Sun protection (SPF 30+) is required daily after treatment.
- Multiple sessions may be needed for best results
Client Initials (acknowledging review): Initials*
Post-Treatment Care

I understand that after any treatment:
- I must avoid sun exposure, tanning, hot tubs, saunas, intense workouts for 24–48 hrs.
- I must apply SPF 30+ daily.
- I may be advised to use soothing creams (aloe vera).
- Results vary based on skin type, condition, and compliance.
Client Initials (acknowledging review): Initials*
Consent
I certify that I:*

Have read and understood this consent form.Have disclosed all relevant health history.Understand the risks, benefits, contraindications, and alternatives.Consent to the treatment selected and release the practitioner/clinic from liability for known and unforeseen risks.
Treatment(s) Selected Today*

Laser Hair RemovalIPL Skin TreatmentPico Laser
Client Signature (If under 18 signature of parent or guardian)*
Date*

MonthDayYear
Should be Empty:

Laser & Light-Based Treatment Intake Form

General Information

Contraindications

Pre-Treatment Acknowledgment (Applies to All Laser Treatments)

Risks (All Treatments)

Treatment-Specific Information

IPL Skin Treatments

Post-Treatment Care

Consent