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44365 Premier Plaza, Suite 120, Ashburn, Virginia 20147
703-726-8100
guestservices@amenitydayspa.com
Home
Services
Facial & Skincare
Massage
Couples Services
MediSpa Services
Body Treatments
Manicure
Pedicure
Soho Hair Studio
Hair Removal
Lash & Eyebrow
Permanent Makeup
Our spa
Client Forms
About Us
Our Team
Spa Etiquette
Careers
Photo gallery
News
Testimonials
Membership
Specials
Bridal / Parties / Groups
Bridal Packages
Spa Parties / Groups
Gift Cards
Contact
Appointments
Repeat Laser Treatment
PERSONAL HISTORY
First Name
Last Name
Date
MM slash DD slash YYYY
Email Address
Home Phone
Mobile Phone
TO 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 Above
List all skin products used in past two weeks, both prescription and non-prescription
4. Have you had any changes in the appearance of your skin from any of the areas previously treated for laser hair removal?
Yes
No
If YES, explain:
5. Pregnant?
Yes
No
Signature
My 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.
Date Signed
MM slash DD slash YYYY
TO BE COMPLETED BY CLINICIAN:
Previous laser treatment with adverse reactions:
Yes
No
Response to previous treatment
% estimated hair loss
History of keloid scarring
Yes
No
Active infection of history of herpes in treatment area?
Yes
No
Accutane use within the past 6 months?
Yes
No
Chemical Peel/Retina/Renova, etc. within past 8 weeks?
Yes
No
Suntan/tanning bed/self-tanning lotion within past 8 weeks?
Yes
No
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