Repeat Laser TreatmentPERSONAL HISTORY First Name Last Name Date MM slash DD slash YYYY Email Address Home PhoneMobile PhoneTO BE COMPLETED BY CLIENT:1. List any medications you are currently taken or have taken within the past two weeks:2. List any new medical conditions or skin conditions diagnosed since your last treatment:3. Circle any of the following conditions that apply since your last visit: Suntan or extended sun exposure in past 8 weeks Tanning booth or self-tanning solution past 8 weeks History of herpes in site to be treated Permanent makeup Facial chemical peel in past 2 weeks Accutane within past 6 months None of the AboveList all skin products used in past two weeks, both prescription and non-prescription4. Have you had any changes in the appearance of your skin from any of the areas previously treated for laser hair removal? Yes NoIf YES, explain:5. Pregnant? Yes NoSignatureMy signature below indicates that I hereby renew my consent for another treatment for laser services and agree to abide by all aftercare instructions as well as my previously signed consent.Reset signature Signature locked. Reset to sign again Date Signed MM slash DD slash YYYY TO BE COMPLETED BY CLINICIAN:Previous laser treatment with adverse reactions: Yes NoResponse to previous treatment% estimated hair lossHistory of keloid scarring Yes NoActive infection of history of herpes in treatment area? Yes NoAccutane use within the past 6 months? Yes NoChemical Peel/Retina/Renova, etc. within past 8 weeks? Yes NoSuntan/tanning bed/self-tanning lotion within past 8 weeks? Yes No
