Laser/IPL Online Consultation
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Year
Full Name
First Name
Last Name
E-mail
Phone Number
-
Area Code
Phone Number
Medical History:
Bleeding disorder, bruise easily
History of cold sores
History of keloid scarring
Dermalogical conditions
Endocrine/hormone issue
Pacemaker/defibrilator
History of cancer
Photoallergic
List medications taken:
Which Service are you interested in?
List topical products you are currently using (acids, retinol, bleaching cremes etc):
Ethnicity:
Skin Type:
1 - Highly sensitive, always burns, never tans.
2 - Very sun sensitive, burns easily, tans minimally.
3 - Sun sensitive skin, sometimes burns, slowly tans to light brown.
4 - Minimally sun sensitive, burns minimally, always tans to moderate brown.
5 - Sun insensitive skin, rarely burns, tans well.
6 - Sun insensitive, never burns, deeply pigmented (darker skin tones)
Medical Conditions:
List any allergies:
Last exposed to IV (sun or tanning bed):
Passive Tan:
Submit
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