Laser Hair Removal
Consultation Form
Name
First Name
Last Name
Email
example@example.com
Phone number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
-
Month
-
Day
Year
Date
Emergency contact name
Emergency contact phone number
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Have you ever had laser hair removal before?
Yes
No
Do you have a history of skin conditions? (e.g, eczema, psoriasis, rosacea, etc)
Yes
No
If yes, please explain:
Do you have any of the following conditions?
Pregnancy
Diabetes
Epilepsy
Autoimmune Disorders
History of skin cancer
Heart disease
Other medical conditions (please specify:)
Please explain:
Are you currently taking any medication?
Yes
No
If yes, please explain:
Do you have any of the following?
Accutane or other oral acne medications
Topical steroids
Blood thinners
Other (please specify:)
Please explain:
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What is your skin type? (Based on the Fitzpatrick scale)
Type 1: Very fair, always burns, never tans
Type 2: Fair, burns easily, tans minimally
Type 3: Medium, sometimes burns, tans easily
Type 4: Olive skin, very rarely burns, tans very easily
Type 5: Dar skin, very rarely burns, tans very easily
Type 6: Very dark skin, never burns, tans very easily
Do you have a history of hyperpigmentation or hypopigmentation?
Yes
No
If yes, please explain:
What area(s) of the body are you seeking treatment for?
Face
Underarms
Bikini area
Legs
Back
Chest
Other
If other, please specify:
What is the current hair colour in the area(s) being treated?
Blonde
Brown
Black
Red
Grey/White
Other
If other, please specify:
What is the current hair texture in the area(s) being treated?
Fine
Medium
Coarse
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What is your goal for laser hair removal treatment?
Permanent hair reduction
Smooth sin with minimal hair growth
Other
If other, please specify:
Are you concerned about any of the following?
Skin irritation/redness
Other concerns
If other, please specify:
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Consent & Acknowledgement
I understand that results may vary and multiple sessions are often required to achieve optimal results.
I acknowledge that I have provided accurate and complete information to the best of my knowledge.
I understand the possible risks, including sin irritation, redness and changes in pigmentation, and I consent to the treatment plan recommended by the practitioner.
Signature
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