First Time LaserStep 1 of 250%PERSONAL HISTORY First Name Last Name Nickname Date of Birth MM slash DD slash YYYY AgeOccupationAddress Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact NameEmergency Contact Phone6. Which of the following best describes your skin type? Always burns, never tans Always burns, sometimes tans Sometimes burns, always tans Rarely burns, always tans Brown, moderately pigmented skin Black skin7. With what temperature water do you cleanse? Cold Warm HotMEDICAL HISTORYAre you currently under a physician’s or dermatologist’s care? Yes NoIf yes, for what reason?Have you ever suffered from any of the following: Cancer Diabetes Epilepsy Hepatitis HIV Thyroid Heart Problems High Blood Pressure Hormone Imbalance Hysterectomy Varicose Veins None of the AboveList all medications taken regularly:List all vitamins taken regularly:Do you have any allergies? Yes NoIf YES, list:Answer the following Do you smoke? Have you ever had a chemical peel? Do you use Retin-A? Do you use Accutane? Have you used any other acne drugs? Do you follow a restricted diet? Do you exercise regularly? Do you have a regular sleep pattern? Have you had your hair frosted, highlighted, or chemically lightened? Do you wear contact lenses? Do you have metal implants or a pacemaker? None of the Above8. Do you have any specific skin problems pertaining to your face? Yes NoIf YES, specify:9. Do you have any specific skin problems pertaining to your body? Yes NoIf YES, specify:10. Check all skincare products you are currently using: Soap Toner Masque Cleanser Moisturizer Scrub/Peel Other (specify)Other (specify)11. Have you ever had a spa treatment before? Yes NoIf YES, specify:OIL SECRETIONDo you experience breakthrough, oily shine during the day? Yes NoDo you experience breakouts? Yes NoMOISTURE HYDRATIONHow much plain water do you consume daily?Do you take laxatives or diuretics? Yes NoHow many alcoholic beverages do you consume weekly? 1-3 4+Check any of the following conditions you experience on your skin: Flakiness Tightness Obvious DrynessDo you use sunblock? Yes NoIf YES, what SPF?CAPILLARY ACTIVITYDo you burn easily in moderate sunlight? Yes NoDo you blush easily when nervous? Yes NoDo you have a tendency toward redness? Yes NoNERVE ACTIVITYWhat do you consider your pain threshold to be? Low Medium HighHave you ever experienced any claustrophobia? Yes NoWhat type of massage pressure do you prefer? Low Light Medium Firm Very FirmHave you had any recent injuries? Yes NoIf YES, explain:Are there any areas that require special attention? Yes NoIf YES, explain:Are there areas of your body that you would prefer your therapist avoid? Yes NoIf YES, explain:Check any of the following to which you have had a reaction: cosmetics pollen animals medicine food fragrance iodine AHAs sunscreen other (specify)other (specify)FEMALE CLIENTS ONLYAre you taking oral contraception? Yes NoAre you pregnant or trying to become pregnant? Yes NoMALE CLIENTS ONLYHow do you typically shave? Wet DryDo you experience irritation from shaving? Yes NoDo you experience ingrown hair? Yes NoSignatureMy signature below indicates, to the best of my knowledge, the information I have provided is correct and complete, and I have not withheld any information that may be relevant to my treatment. Date Signed MM slash DD slash YYYY Informed Consent for Hair RemovalCustomer’s nameDate MM slash DD slash YYYY Treatment sites: mono-brow, lip, chin, neck, face, arms, fingers, chest, areola, linea, underarms, back, buttocks, bikini, labia, scrotum, thighs, lower legs, feet, and toes.CombinationsPrevious hair removal methods(shaving, tweezing, waxing, depilatories, electrolysis, laser)The purpose of this procedure is to diminish or remove unwanted hair. The procedure requires more than one treatment and may produce permanent hair removal. The total number of treatments will vary between individuals. On occasion there are patients that do not respond to treatments. The treated hair should exfoliate or push out in approximately 2-3 weeks.Alternative methods are waxing, shaving, electrolysis, and chemical epilation.The following problems may occur with the hair removal system.However slight, there is a risk of scarring.Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation (browning) and Hypo-pigmentation (lightening) have also been noted after treatment. These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Avoiding sun exposure before and after the treatment reduces the risk of color change.Infection: Although infection following treatment is unusual, bacterial fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individual with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. Systematic reactions (which are more serious) may result from prescription medicines.I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience. ACKNOWLEDGEMENT: My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release(individual) andMy questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release(facility) and(doctor) from all liabilities associated with the above indicated procedure.Client/Guardian SignatureDate MM slash DD slash YYYY Laser Technician SignatureDate MM slash DD slash YYYY Post Treatment Instructions:Immediately after the treatments, there should be redness and bumps at the treatment area, which may last up to 2 hours or longer. You should apply an ice pack, as there may be mild swelling. It is normal for the treated area to feel like sunburn for a few hours. Apply gloBarrier Balm to your skin at this time. You should use a cold compress if needed. Avoid any trauma to the skin for up to 2-5 days, such as bathing with very hot water, strenuous exercise, or massage.Makeup may be used after the treatment has quit swelling unless there is epidermal bleeding or blistering. It is recommended to use new makeup to reduce the possibility of infection. Keep the area moist this will help the dead hair exfoliate from the follicle, so use moisturizer frequently and freely on the treated area. Any moisturizer without alpha-hydroxy acids will work.Avoid direct sun exposure and tanning beds for 1-2 months and throughout the course of the treatment so as to reduce the chance of dark or light spots. Use SPF 30 sunscreen at all times throughout the treatment when going outside.Avoid picking or scratching the treated skin. DO NOT USE any other hair removal methods or products on the treated area during the course of your laser treatments, as it will prevent you from achieving your best results.You may shower after the laser treatments, and use soap, deodorant, etc. the treated area may be washed gently with a mild soap. Skin should be patted dry and NOT rubbed. You may apply deodorant after 24 hours.Anywhere from 5-30 days after the treatment, shedding of the hair may occur and this may appear as new hair growth. This not new hair growth, but dead hair pushing its way out of the follicle. You can help the hair exfoliate by washing or wiping with a washcloth.Hair re-growth occurs at different rates on different areas of the body. New hair growth will occur for at least three weeks after treatment.Stubbles, representing hair being shed from the hair follicle, will appear within 10-20 days from the treatment date. This is normal and will fall out quickly.Call our office at 703-726-8100 with any questions or concerns you may have after the treatment.CAPTCHA
