• FOTONA LASER THERAPY — CLIENT INTAKE & SAFETY SCREENING

    Please complete all questions. Your provider will review this information before treatment.

  • Client Details

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Treatment Goals

  • Select all the apply *
    Rows
  • Have you had laser or light-based treatment for this concern before?*

  • General Medical History

  • Have you ever been diagnosed with or currently have any of the following?*
    Rows

  • Cancer History

  • Have you ever had cancer?*
  • Have you been medically cleared for elective laser treatment?*

  • Skin History and Current Treatment Area

  • Are you currently experiencing any of the following?*
    Rows
  • Does the area being treated currently have any open skin, rash, infection, cold sore, significant irritation, or suspicious/ new lesion?*
  • Do you tend to develop dark or light marks after acne, injury, waxing, injections or procedures?*
  • History of raised scars / keloids / hypertrophic scars?*

  • Sun, Tanning & Photosensitivity

  • Recent significant sun exposure to treatment area?*
  • In the last 14 days have you used any of the following?*
  • Have you ever been diagnosed with photosensitivity, photodermatitis, porphyria, or a photosensitive autoimmune condition?*
  • Do you devleop an unusual rash, blistering, burning, or severe reaction after sun/light exposure?*
  • Do any medications or supplements you take make you light/sun sensitive?*

  • Medications & Supplements

  • List ALL prescription medications, over the counter medications, vitamins, supplements, herbal products and topical medications: *
    Rows
  • Have you ever, or are you currently using any of the following?*
    Rows

  • Pregnancy & Hormonal Status

  • Are you pregnant or trying to become pregnant?*
  • Are you currently breastfeeding?*
  • Date of last menstrual cycle:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Recent Procedures & Skincare

  • Have you recently had waxing, sugaring, threading, chemical peel, dermaplaning, microdermabrasion, microneedling, IPL, laser, RF, surgery, or another energy-based treatment in the treatment area?*
  • Are you currently using any of the following:*

  • Injectables, Fillers & Implants

  • Botox / Dysport / Xeomin in treatment area?*
  • Dermal filler in treatment area?*
  • History of injection complication in treatment area (delayed swelling, nodules, infection, vascular complication, or unusual reaction?*
  • Implanted electronic medical device?*

  • Allergies & Herpes History

  • Medication / topical / latex / adhesive / anesthetic allergies or sensitivities?*
  • History of cold sores, fever blisters, oral/genital herpes, or shingles?*
  • If yes, currently taking antiviral?

  • Laser Specific Safety Questions

  • If you have had previous laser experience, have you ever had any of the following:*

  • Treatment Area

  • Requested Areas:*
  • Does the treatment area contain:*

  • Client Declaration & Consent

  • Declaration by the client receiving treatment

    I have received sufficient information about the aesthetic treatment I am to receive and read the information sheet about this procedure. I have detailed explanation of the procedure I am to undergo. I fully understand the aims and objectives of the treatment. I am aware of the limitations, possible risks and unexpected side effects that may not be possibly anticipated beforehand; as well as the intended benefit to my appearance and wellbeing. I also understand the usual possible range of variation in the expected outcome of the treatment, which has been explained to me by the practitioner performing the treatment- procedure. I understand that the local anaesthetic may be applied or injected. I have had further opportunity to consult a medically qualified professional and have all my questions answered to my entire satisfaction. Having considered all aspects, I have decided to have this treatment of my own accord with sole intention the anticipated benefit from the same, provided by the practitioner performing the treatment procedure. I understand that I will not be able to sue my provider in case of any complications or be entitled to a refund if I am not happy with my procedure. I agree to follow the post treatment advice provided. I hereby consent to receive the treatment described herein. I further consent to be photographed before, during and after treatment. I understand that these photographs would remain the property of the professional practice and will not be used for marketing purposes without my explicit permission. I understand my right to withdraw consent at any time.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Provider Only - Laser Safety Clearance

  • Review against the contraindications and precautions for the SPECIFIC Fotona device, wavelength, handpiece, and treatment protocol being performed.
  • Should be Empty: