Laser Services New Patient Packet
|
|
- Dorothy Bennett
- 5 years ago
- Views:
Transcription
1 Laser Services New Patient Packet Informed Consent for Laser Services This consent form is intended to provide you with the information needed to make an informed decision whether or not to undergo laser therapy treatment for hair removal, pseudofollicular barbae, photorejuvenation, vascular and/or pigmented lesions. Please read this and be sure you understand it completely before making your decision. Laser therapy treatment involves intense light and while it is effective in most cases, there is no guarantee made that a particular patient will benefit from the treatment. Purpose of the Treatment The purpose of this treatment is to reduce and/or eliminate unwanted hair or skin conditions. The Light Sheer Diode is a medical laser that emits a pulse of light that penetrates the skin to a depth of approximately 1mm, Light heats the hair root and causes the hair to shed/fall out within 1-3 weeks after a treatment. Hair grows in 3 growth cycles and is only connected to the hair root during the first cycle, this is why it may take 4-6 treatments to see hair reduction as each hair follicle must be treated twice during the first cycle. In photorejuvenation, the laser heats the water molecules within the skin and triggers collagen to rebuild. With skin lesions, light heats the chromophore within the vascular system destroying the lesion, this may also take several treatments to accomplish. Procedure Most visits last approximately 30 minutes depending on the area treated. During you first visit a Registered Nurse will go over your medical history and examine you suitability for the treatment. During the treatment sessions, the pulsed laser will be applied to the areas of concern and safety and comfort measures will be taken including: ice, cold gel, cooling devices and protective eyewear. Risks, Discomforts, and Complications Clients with freshly tanned or burned skin, using medications which require limited exposure to sunlight or other light (see Photosensitive Med list or ask the front desk), clients suffering from diabetes or bleeding disorders are not permitted to undergo treatment. The most common side effects of this treatment are: Pain Many clients experience some discomfort during the treatment. Clients typically report a very momentary sting on the exposed area. This discomfort may range from minimal to moderate but does not last longer that a few seconds. A mild sun-burn sensation may follow for typically up to one hour and can be reduced with application of cooling and soothing creams Perifollicular erythema/oedema This is swelling or induration around the the hair follicle itself and the severity and duration of the rash depend on the intensity of the treatment and the sensitivity of the area being treated. These phenomena may be reduced with application of cooling and/or inflammatory creams. Superficial wound a crust or blister may occur on the exposed area. It is important not to manipulate or pick which may otherwise lead to scarring. It will heal in 5 to 10 days. Pigmented changes the treatment may heal with changed pigmentation or color. Such a change most often occurs with darker skin or when the area has been exposed to sunlight. It is important to protect the treated area from exposure to sunlight for 3 weeks following treatment. With some client these changes may occur despite adequate protection from sunlight. The change pigmentation, which may include more color (hyper-pigmentation) or less color (hypopigmentation) usually reverts to its original appearance in 3 to 6 months although occasionally a pigment change may be permanent. Scarring there is a small chance of scarring, which could include enlarged scars know as hyper-tropic scars and, very rarely, abnormal heavy raised scar formations called keloid scars. Fragile Skin the skin at or near the treatment area may become fragile. To avoid tearing, this area may not be rubbed or abraded, nor should makeup be applied to the area while this persists. Excessive Swelling Page 1 of 5
2 immediately after treatment, especially when the treatment involves the cheeks or upper lip, swelling may occur. This condition is temporary, not harmful, and usually subsides in 7 to 10 days if not sooner. Bruising A blue-purple bruise may occur at the treated area. The bruise usually disappears in 5 to 15 days. As it fades a rust discoloration may remain but that usually fades within 1 to 3 months. Please read and initial each statement. Complete, underline or circle individual selection accordingly. I authorize Excellence Medical Group to perform LightSheer INFINITY treatments on me in an effort to improve Hair Reduction / Pseudofolliculitis Barbae / photorejuvenation/vascular or pigmented lesions Other: _ I understand the Risks, Discomforts, and Complications and agree to follow guidelines as stated previously and on the aftercare instructions. I understand that there is a rare possibility of side effects or serious complications including permanent discoloration and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility. I understand that sun exposure or tanning of any sort may increase the chance for complications. The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered. Pre and post-care instructions have been discussed and are completely clear to me I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment and how many sessions will be required I consent to photographs being taken for the purpose of documenting my progress and response to the treatment and be kept solely in my medical record I consent to photographs being used for medical education or publication with my discretion and not revealing my identity (optional) I agree to review the Laser Pre-treatment Questionaire/Compliance Checklist along with my Physician/Nurse Practitioner/Registered Nurse and bring accurate and updated data, to the best of my knowledge Page 2 of 5
3 Laser Pre-treatment Questionnaire/Compliance Checklist Determining your Fitzpatrick Skin Type: (Circle the column that applies to you) What is the natural color Sandy red Blond Chestnut, dark Dark Black of your hair? blond What is the color of sun unexposed skin areas? Reddish Very pale Pale with beige tint Light Dark Do you have freckles on sun exposed areas? Many Several Few Incidental None What happens when you are in the sun TOO long without sunblock? How well do you turn? Do you turn within one day of sun exposure? How does your face respond to the sun? When did you last expose yourself to the sun or artificial sun treatments? Do you expose the area to be treated to the sun? Painful redness, blistering, Hardly or not at all Blistering followed by Light color tan Page 3 of 5 Burns, sometimes followed by Reasonable tan Rarely burns Tan very easily Never had a problem Turn dark very quickly Never Seldom Sometimes Often Always Very sensitive Sensitive Normal Very resistant More than 3 months 2-3 month 1-2 months Less than 1 month Never had a problem Less than 2 weeks Never Hardly ever Sometimes Often Always Total score of all columns circled: Using the table below, circle your skin type according to the total score you calculated above points = Skin type I points = Skin type III points = Skin type V & VI points = Skin type II points = Skin type IV Does the skin type determined match the description of you below? Yes/No (circle one) Skin Skin Hair Colour Eye Colour Characteristics Ethnic Group Type Colour I Very fair Blonde Blue/green Never tan, always burn European II Fair Light, Green/hazel Sometimes tan, but European chestnut usually burn III Light olive Chestnut Hazel Usually tan, but sometimes burn European, Hispanic, Darker Caucasian IV Olive Dark Dark Always tan, never burn Asians, Indians, Hispanic, V Dark Brown/black Brown/black Never burn Creole, Hispanic, Mulatto VI Very dark Black Black Never burn Black-skinned, African
4 Pre-treatment Questions: (Circle the column that applies to you) Any natural or artificial sun exposure in the treatment area in the past 3-4 weeks Use of self tanners or tan enhancer caps within the past 3-4 weeks pre-op plan Use of Photosensitive herbal preparations (St John s Wort, Ginkgo Biloba, etc.), aromatherapy, or essential oils (citrus, peppermint, etc.) Use of steroids or steroid creams YES Use of Antibiotics in the last 2 weeks YES Pregnant or possibility of pregnancy, postpartum or nursing YES Presence or recent history of active cold sores or herpes simplex virus YES Any tattoo and/or dysplastic nevi on requested treatment area that should YES be protected? Previous hair removal procedures on requested treatment area (other IPL/laser, wax, electrolysis, etc ) Within the past 6 weeks? YES Previous skin procedures on requested treatment area (Laser, Botox, fillers, peels, etc...) in the last 4 weeks Medical History/Good Faith Exam: YES YES YES:... YES: what/when?. YES: what/when?. Do you have any allergies (medication, food, lotions, latex, ect.)? Please list Do you have a history of? (circle) Active Skin Disease Anemia Asthma Bleeding Disorder Blood Pressure Problems Bowel Disease Cold sores/ Herpes/Blisters Connective Tissue Disease Deep Dermal Scarring Diabetes Eczema Facial Nerve Palsy Hay Fever Hepatitis A, B, or C Hormonal or endocrine disorders (PCOS/thyroid) Keloid Scarring Liver Disease Metal Implants Myasthenia Gravis Neuropathy Porphyria Psoriasis Seizures Sinus Problems Stomach Ulcers Systemic Lupus Erythematosus Inflammatory skin conditions (dermatitis, active acne, livedo reticularis, erythema ab igne, etc.) Skin cancer Vitiligo Do you have a family member with a history of? (circle) Amyotrophiic Lateral sclerosis Asthma Eczema Facial Nerve Palsy Hay Fever Keloid Scarring Lamvert-Eaton Syndrome Motor neuropathy Myasthenia Gravis Porphyria Sinus Problems Systemic Lupus Erythematosus If yes, please specify who has it Inflammatory skin conditions (dermatitis, active acne, etc.) Skin Cancer List current medications including any medications taken in the last 4 weeks: Do you drink? Yes/No Do you smoke? Yes/No If Yes, how much/often? If Yes, how much/often? Page 4 of 5
5 What treatments/medications are you interested in having in the future? (circle) Botox/Dysport Chemical Peel Dermal Filler Dermaplaning Foot Detox Hydroquinone IPL Laser Hair Removal Laser Skin Resurfacing Latisse Microdermabrasion Velashape Retin-A Skin Tightening Sclerotherapy Venus Freeze Permanent Cosmetics Spider Veins My signature certifies that I have duly read and understood the content of this Laser Service New Patient Packet and gave the accurate information as to my health condition. I hereby freely consent to LightSheer INFINITY treatments. Name of patient (please print) Signature of patient Date Name of RN (please print) Signature of RN Date Name of Physician/NP (please print) Signature of Physician/NP Date Page 5 of 5
Personal Profile and Health History
--CAPITAL AESTHETICS Personal Profile and Health History Name: Home Phone: Address: Work Phone: City/State/Zip: Date of Birth: Age: Gender: M F Occupation: Email address: How did you hear about us? What
More informationEast Hill Medical Group
Name: of Birth: Address: City: State: Zip: Home Tel. #: Cell #: Employer: Occupation: Emergency Contact: Relationship: Phone: Email: How Referred: Parents Ethnic Background: Previous Treatments Year: Area(s):
More informationAREA OF BODY TATTOO IS SITUATED?
CLIENT CONSULTATION LASER TATTOO REMOVAL FORM Address: Date of Birth: Suburb: State: Postcode: Telephone: Work: Mobile Home: Other: Email Address: How did you hear about us? Tattoo Removal Colours in tattoo
More informationWelcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine
MedSpa 1064 Suites at Somerset Square 140 Glastonbury Blvd. Glastonbury, CT 06033 860.657.1064 Welcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine This form is to introduce
More informationHEALTH HISTORY INFORMATION
HEALTH HISTORY INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:
More informationInformed Consent For Facial Rejuvenation/Collagen Remodel
Informed Consent For Facial Rejuvenation/Collagen Remodel Client s name: Date: I authorize SilkySkin Laser Centers to perform the laser procedure. You will be treated with the Cynosure Elite TM laser,
More informationIntake Form Chemical Peels, Microdermabrasion, and Facials
Intake Form Chemical Peels, Microdermabrasion, and Facials Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: 0 Female 0 Male Home Phone: Cell Phone: Leave messages
More informationPersonal Profile and Health History
--CAPITAL AESTHETICS Personal Profile and Health History Name: Home Phone: Address: Work Phone: City/State/Zip: Date of Birth: Age: Gender: M F Occupation: Email address: How did you hear about us? What
More informationForename Surname... SOPRANO ICE SHR LASER CONSULTATION FORM
Forename Surname... SOPRANO ICE SHR LASER CONSULTATION FORM 1 SOPRANO ICE SHR PERSONAL INFORMATION Gender: Male/Female Date of birth.age. Home address..postcode.. Telephone..Mobile.. Email address.. GP
More informationEast Hill Medical Group
Name: of Birth: Address: City: State: Zip: Home Tel. #: Cell #: Employer: Occupation: Emergency Contact: Relationship: Phone: Email: How Referred: Parents Ethnic Background: Previous Treatments Year: Area(s):
More informationContact Information. Idaho Falls. Idaho Falls, ID (208) (307) NAME. City / state / zip
Contact Information NAME physical street address City / state / zip Home phone cell phone email address want monthly specials? date of birth Age gender Male female How did you hear about us? WHICH AREAS
More informationHEALTH HISTORY. Name Date DOB Age. Home Phone Work Mobile Other
HEALTH HISTORY To ensure both the effectiveness and the safety of your treatment, please complete this health history as accurately as you can. PERSONAL INFORMATION Name _ Date DOB Age Address _ City State
More informationInformed Consent for Light Energy Tattoo Removal
Dr. Joseph G. Protain 813 Kentwood Dr. Boardman, OH 44512 (330)953-3515 Informed Consent for Light Energy Tattoo Removal Customer s name: Date: I, consent to and authorize and members of his/her staff
More informationChameleon Medical Spa NEW CLIENT HISTORY
NEW CLIENT HISTORY This information will allow your professional skincare specialist to provide the optimum products and services. First Name: Last Name: Date: Birth date: Address: City: State:_ Zip code:
More informationHair To Bare South. Client Name: Date:
Hair To Bare South Client Name: Date: I authorize Rachelle Stokes (Hair To Bare South) to perform the treatments. The purpose of these treatments is to diminish or remove unwanted hair. The quantity of
More informationIPL CONTRAINDICATIONS
IPL CONTRAINDICATIONS CONTRAINDICATIONS AND EXCLUSION CRITERIA FOR IPL APPLICATOR TREATMENTS CONTRAINDICATIONS - Please initial that you don t have any of these conditions. Superficial metal or other implants
More informationBrilliant Bodywork. Name: Date: Address: City: State: Zip: Home Phone: Business Phone: Cell Phone: Date of Birth: address:
Brilliant Bodywork Skin Care History Questionnaire and Waiver Please answer the following questions so that your Skin Care Specialist may have a better understanding of your general health and lifestyle,
More informationINFORMED CHEMICAL PEEL CONSENT. 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands.
INFORMED CHEMICAL PEEL CONSENT 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands. 2. Depending on the chemical peel site, there may be redness and/or irritation and
More informationCLIENT QUESTIONNAIRE TODAY S DATE: SPECIFIC CONCERNS REGARDING YOUR SKIN (CHECK ALL THAT APPLY) I AM INTERESTED PRIMARILY IN:
CLIENT QUESTIONNAIRE TODAY S DATE: NAME: DATE OF BIRTH: SPECIFIC CONCERNS REGARDING YOUR SKIN (CHECK ALL THAT APPLY) Fine Lines/Wrinkles Dark Circles Puffy Eyes Blotchiness/Discoloration Uneven Skin Tone
More informationClient Intake Form. Name: Date: Address: City: ST: Zip: Phone:
Client Intake Form Name: Date: Last First Address: City: ST: Zip: Email: Phone: How did you hear about Skin Renew Day Spa? What are your main concerns? How long have you been experiencing your current
More informationMassey Medical. Medical History (Dermal Filler) MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox:
Medical History (Dermal Filler) Name: Date: _ Date of Birth: Phone: _ MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox: NO YES Allergies history of severe allergy or anaphylaxis.
More informationPatient Information. M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Whom may we thank for referring you?
Today's : First Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Patient Information Last Name Email: Primary Care Physican:
More informationIPL CONSULTATION AND LIABILITY DOCUMENTATION
Name...... Address:... Date of Birth:... Suburb:... Postcode:... Home Phone:... Mobile:... Email Address:... How did you hear about us?... Contact in case of emergency:... Place a tick in the areas of
More informationPre- & Post Hair Removal Instructions and Home-Care Regimen
Pre- & Post Hair Removal Instructions and Home-Care Regimen Pre-Hair Removal Regimen: Avoid sun exposure or tanning beds to the area being treated. The laser may be less effective on burned or tanned skin.
More informationNEW CLIENT FORM. Address: City: State: Zip: FITZPATRICK CLASSIFICATION SYSTEM: Please select the skin type seems to best describe your skin
OREGON LASER & WELLNESS CENTER 4370 SE KING ROAD SUITE 105 MILWAUKIE, OR 97222 PHONE: 503 305 7704 or 971 263 7679 Date: Name: NEW CLIENT FORM Address: City: State: Zip: Email: Home Phone: Work Phone:
More informationNewport Cosmetic Center
Shirin Afrasiabi, M.D, Inc. 2301 Newport Blvd, Costa Mesa, Ca 92627 (949) 548-5700 Appointment: Initial. We require a valid Credit Card at the time of booking to secure your appointment Cancellation and
More information5504 Backlick Road Springfield, Virginia
Name: Address: Phone: City: Zip Code: Cell: Phone: Text Cell Phone email How did you hear about us: General Health State: Contact me by 1. Rate your level of stress: (5 = highest, 1= lowest) 5 4 3 2 1
More informationClient Information Sheet
Esthetic Laser Clinic 8381 Old Courthouse Road Suite 300 Vienna, VA 22182 (703) 288 0085 www.elaserclinic.com Client Information Sheet Last Name First Name: Address City State Zip Code D.O.B. (MM/DD/YY)
More informationMicroblading Consent and Release Agreement
Microblading Consent and Release Agreement This form is designed to give information needed to make an informed choice of whether or not to undergo a Microblading semi-permanent make up application. If
More informationAlani Medical Spa Medical History and Information
Alani Medical Spa Medical History and Information Birth date: _/_/_ SS#/_/_Email_ Today s Date: _/_/_ Name: (Mr.) (Mrs.) (Miss) Home Address: _ Work Address: _ Home Phone: ( ) Work Phone: ( ) _ Phone Number
More informationBeautiful You LLC. Laser Hair Removal Pre/Post Treatment Care
Beautiful You LLC Laser Hair Removal Pre/Post Treatment Care Pre-Treatment Instructions Avoid deep tanning, including tanning beds and tanning creams, 2 weeks before and 1 week after treatment. If you
More informationCLEAR TOE INTAKE INFORMATION
CLEAR TOE INTAKE INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:
More information513 West Maple Ave West, Vienna, VA
`MEDICAL HISTORY FORM Last Name: First Name: Address: City: State: Zip Code: Telephone: Home: Work: Cell: Date of Birth: Sex: Female Male Family Doctor: Phone: Pharmacy: Phone: Emergency Contact: Phone:
More informationHISTORY CARD. [ ] Face: Nose [ ] Face: Sideburns [ ] Glabella [ ] Gluteal [ ] Hands & Feet
HISTORY CARD Name: Date of Birth: / / Street Address: City: State: Zip: Telephone: (Home) Email: MEDICAL HISTORY Are you under a doctor s care: Yes [ ] No [ ] Please list any recent surgeries/injuries:
More informationBrow and Beauty Bar - Permanent Makeup
General Consent and Procedure Permit Clients Full Name Mr/Mrs/Miss/Ms Address e-mail I hereby authorize Erin Exline to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises
More informationClient Questionnaire Skin & Health
Client Questionnaire Skin & Health Please answer the following questions thoroughly and completely, as this provides a better understanding of your general health, lifestyle and skin care concerns; thereby
More informationLaser Skin Resurfacing what to expect
Laser Skin Resurfacing what to expect Laser skin resurfacing is a treatment to reduce facial wrinkles and skin irregularities, such as blemishes or acne scars. The technique directs short, concentrated
More informationLaser Hair Removal. Name Date of Birth. Address City State Zip. Home Tel. # Cell # How Referred
Laser Hair Removal Name of Birth Address City State Zip Home Tel. # Cell # Email How Referred Ethnic Background Previous Treatments Year Area(s) Hair and Skin Question - DO NOT use White, Jewish or Caucasian.
More informationDate: Date of Birth: Gender: Male Female. City: State: Zip: Caucasion a African-American Hispanic Asian East Indian American Indian
Contact Information: Date: Date of Birth: Gender: Male Female Name: Address: City: State: Zip: Home Phone: Work/Day Phone: Cell: Email: Emergency Contact: Emergency Contact Phone: Medical Background Ethnic
More informationImbue Aesthetics & Wellness PATIENT REGISTRATION FORM
Today's Date Legal Name Marital Status Sex DOB Age Mailing Address Preferred Phone Number Email Do we have your permission to add you to our email list to receive newsletters and promotions? YES NO Emergency
More informationClient Medical History Form
Client Medical History Form Date Birthdate Name Address Phone Email Emergency Contact Person Phone Do you have or previously had any of the following: (Circle YES or NO) YES NO History of MRSA YES NO Botox
More information513 Maple Ave West, Vienna, VA
CLIENT INFORMATION AND CONSENT FORM: SKIN CARE Name Date of Consultation Address City State Zip Home phone ( ) Cellular phone ( ) E-mail Date of birth Emergency contact and telephone number How did you
More informationWelcome to Bella! Give the Gift of Bella. A few tips to prepare you for your first visit: Gift Certificates are just $100 for a $150 value!
Welcome to Bella! We are glad to have you as our guest. We encourage you to visit our website to see all of the exciting new laser and skincare treatments that we offer. Please be aware of our 24 hour
More informationSTATEMENT OF CONSENT AND RECITALS: Please read and initial all lines. Signed
STATEMENT OF CONSENT AND RECITALS: Please read and initial all lines Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow
More informationTouch Up-Color Refresh Policy
Touch Up-Color Refresh Policy All Full Price New Procedures clients receive one Follow up visit for $50 with your initial price per procedure. You must wait at least 30 days before you can be touched up.
More informationClient Medical History Form
Client Medical History Form Date Birth Date Age DL or ID# Name: Address City State Zip Phone Email Emergency contact person Phone Do you presently have or previously had any of the following: (Circle yes
More informationPRODUCT YES / NO BRAND NAME PRODUCT NAME FREQUENCY OF USE
Consultation Form Today s Date: Name: Your Birthday: Spouses Name: Spouses Birthday: Anniversary: Address: City: St: Zip Home Phone: Office Phone: Cell Phone: Email Address: Purpose for visit: How did
More informationConsent and Release Agreement
Consent and Release Agreement This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow Embroidery Semi-permanent make up application. If you
More information(Injection of collagen, hyaluronic acid or other filler materials) INFORMED CONSENT FOR DERMAL FILLER
INFORMED CONSENT FOR DERMAL FILLER (Injection of collagen, hyaluronic acid or other filler materials) INTRODUCTION Dermal fillers are injected just under the skin s surface in order to temporarily correct
More informationClient Medical History Form
Client Medical History Form Today s Date: Birthday: / / Age Name: TXID# Address: Phone: Email: Tattoo Area: Eye Brows (Micro-Blading) Brand of Ink: Bio Touch Pure / / / Emergency Contact: Phone: Do you
More informationLASER TREATMENT INFORMED CONSENT
LASER TREATMENT INFORMED CONSENT PRINT NAME: BIRTHDATE: / / DATE: The following Larson Modality Services are performed by trained, certified, licensed personnel and healthcare providers of Margaret L.
More informationSKIN CARE INTAKE (SCI)
SKIN CARE INTAKE (SCI) Patient Name (Print) Today s Date Street: Date of Birth Apt # Home Phone City, State Zip Code Cell Phone E-Mail How did you hear about REDBAMBOO? Walked by Twitter Groupon Magazine
More informationMenter Cosmetic Institute 3900 Junius Street, Suite 105 by Texas Dermatology Associates Dallas TX, (972) Ext. 255
PRECAUTIONS TO CONSIDER BEFORE FRAXEL TREATMENTS SIX TO TWELVE MONTHS BEFORE TREATMENT: Stop use of Accutane TWO WEEKS BEFORE TREATMENT: Stop use of all Retinols - Retin-A, Tazorac, anti-aging products
More informationGENERAL CONSENT AND PROCEDURE PERMIT FORM
GENERAL CONSENT AND PROCEDURE PERMIT FORM Please read this form fully and sign at the end. If you are unsure about a particular detail of the form, please speak to your therapist. If unforeseen condition
More informationClient Training Guide
Imagine never having to shave ever again Client Training Guide CONFIENT IMAGE CHEZ FRANCE (905) 931-0686 confidentimage@cogeco.net (905) 931-0686 confidentimage@cogeco.net - 1 - LASER HAIR REMOVAL Client
More informationPre Treatment Advice and Procedures
Pre Treatment Advice and Procedures 1. Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear crusty for up
More informationPermanent Cosmetics Contraindications
Permanent Cosmetics Contraindications under 18 years of age diabetes pregnant or lactating women glaucoma skin diseases such as psoriasis, eczema and undiagnosed rashes or blisters on the site that is
More informationCOSMETIC LASER AND AESTHETICS CENTER
COSMETIC LASER AND AESTHETICS CENTER PERSONAL INFORMATION Please complete the following: Date: Name: Date of Birth: Home Address: City: State: Zip: Home Telephone: ( ) Cell: ( ) Work Phone: ( ) Email This
More informationMaya Med Spa 6330 Broadway Blvd. Suite B, Garland, TX Name: Date of birth: Address: Pharmacy of your choice:
Client Consultation Name: Date of birth: Address: Home Phone: Cell Phone: Business Phone: E-mail address: Married: Yes No If yes, anniversary date: Employer: Occupation: Pharmacy of your choice: Does your
More informationConsultation Form: Coffeeberry Peel
Consultation Form: Coffeeberry Peel NAME: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: EMERGENCY CONTACT: EMAIL ADDRESS: OCCUPATION: DOCTORS NAME/SURGERY: We aim to ensure clients have the best possible advice
More informationSkinCeuticals Flagship Advanced Medical Spa
SkinCeuticals Flagship Advanced Medical Spa 570 Long Point Road Mt Pleasant, SC 29464 843-881-0320 Table of Contents Spa Personnel Platelet Rich Plasam (PRP) Treatment Instructions TruSculpt Treatment
More informationAreas of Concern. Patient s Name Last First Date
Areas of Concern What are your main concerns for today s visit? Please check the problem areas that concern you. Include anything you wish to discuss, even if it is not the main reason for your visit.
More informationMicroblading Consent Form Client Medical History: Date Birthdate Age Name Form of Id # Address
Microblading Consent Form Client Medical History: Date Birthdate Age Name Form of Id # Address Phone Email Emergency Contact Person Phone Do you have or previously had any of the following: (Circle YES
More informationNew Patient Registration
New Patient Registration Today s Date: Social Security Number: Name: Last First MIddle How do you like to be addressed: Date of Birth: Address: Street City State Zip Email Address: Preferred Contact Number:
More informationCOSMETIC INTEREST QUESTIONNAIRE
COSMETIC INTEREST QUESTIONNAIRE Patient Name: Date: General appearance or products of interest to you (please check all that apply). Skin care consult Facial veins Neck elasticity Skin care products Facial
More informationClient Information & Health History
Client Information & Health History Name: Address: City: State: Zip Code: Cell#: Work#: Home#: Email: Preferred method of contact: email cell# work# home# Date of Birth: Occupation: How did you hear about
More informationQ-switched Nd:YAG Carbon Laser Facial Further treatment possible using your Tattoo Removal Laser
Q-switched Nd:YAG Carbon Laser Facial Further treatment possible using your Tattoo Removal Laser Carbon Laser Peel plus a mild form of Skin Rejuvenation Course Topics What is a Carbon Laser Facial? How
More informationpatient profile Lifestyle: Are you pregnant or lactating? Name: DOB: Age: Sex: Address: City: State: Zip: Phone:
patient profile Name: DOB: Age: Sex: Address: City: State: Zip: Phone: E-mail: About you: What is your hereditary background? (note all that apply) Nordic / Scandinavian / Irish / English / Asian / Mediterranean
More informationCLIENT HISTORY. May we contact you at these numbers?
CLIENT HISTORY Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Street City State Zip Business Phone: May we contact you at these numbers? Other ID: Referred by: Emergency Contact:
More informationPermanent Makeup Intake Form
Permanent Makeup Intake Form Artist Information (the Artist ): Chrystal Ladouceur 1530 McTavish Road, North Saanich, B.C., V8L 5T3 Client Information (the Client ): First Name Email Mobile Phone Address
More informationConsultation Form: AHA Chemical Peel
Consultation Form: AHA Chemical Peel NAME: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: EMERGENCY CONTACT: EMAIL ADDRESS: OCCUPATION: DOCTORS NAME/SURGERY: We aim to ensure clients have the best possible
More informationNEW CLIENT GENERAL INFORMATION FORM
NEW CLIENT GENERAL INFORMATION FORM First Name: Last Name: Email: Date of Birth: Occupation: Home Phone: Cell Phone: Carrier: Gender: Female Male Preferred Staff Gender: Female Male Preferred Staff Member:
More informationCLINICAL FORMS AND CHARTING
CLINICAL FORMS AND CHARTING CLINICAL Lira Clinical forms to help you chart, analyze and evaluate your client for a successful skin care plan. 110 110 NAME TREAMENT DATE PROFESSIONAL RESURFACING TREATMENT
More informationT R A I N I N G M O D U L E IPL 1
TRAINING MODULE IPL 1 Remington's i-light PRO+ Face & Body gently removes unwanted hair in the comfort and privacy of your own home. Permanent results in just 4 weeks * *Individual results vary. In clinical
More informationPre & Post (BBL)Laser Hair Removal Treatment Instructions
Pre & Post (BBL)Laser Hair Removal Treatment Instructions Pre-Treatment Recommendations: Apply SPF 30 (or higher) sunblock at all times on areas to be treated that are exposed to any sun. Shave the area
More informationModule 1. Introduction to Aesthetic Medicine: Nonsurgical
Module 1 Introduction to Aesthetic Medicine: Nonsurgical What is aesthetic medicine? Well really it s about treatments, whether it be nonsurgical or surgical, to reshape normal structures of one s body
More informationPre-Treatment Advice and Procedures
1 Client copy Pre-Treatment Advice and Procedures Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear "crusty"
More informationCOLORADO AESTHETIC CENTER
COLORADO AESTHETIC CENTER 9320 Grand Cordera Parkway, Suite #250 Colorado Springs, CO 719.387.7800 Skin and Health Questionnaire Please answer the following questions thoroughly, as this provides a better
More informationMedication Name Reason Taken Dosage Last Date Taken
CLIENT HISTORY FORM Print Name Location of Service: Email Birth Date Age Gender @ Female Address City State / Male Emergency Contact Name and Number Home Phone ( ) Cell Phone ( ) Today s Procedure Description:
More informationInformed Consent for Dermal Filler
Informed Consent for Dermal Filler NAME: DATE OF BIRTHG: ADDRESS: CELL PHONE: EMAIL: www.medicaleyecenter.com Please initial all of the following sections confirming that you have read and understand each
More informationSALIBIAN MOSSI. Name Last First Middle. Address Apt. City State Zip. Home Phone Cell Phone Work Phone. Address
Name Last First Middle Address Apt. City State Zip Home Phone Cell Phone Work Phone Email Address Age Date of Birth Sex Height Weight Marital Status Drivers License # Social Security # Employer Occupation
More informationAesthetic Patient Form
Aesthetic Patient Form Name: Date: Address: City: State: Zip: Home Phone: Work Phone: Cell: Age: Date of Birth: Occupation: Email: FITZPATRICK CLASSIFICATION SYSTEM: Please select the skin type that seems
More informationTimeless Makeup, LLC
Timeless Makeup, LLC CLIENT REGISTRATION (Please complete all blanks) I. CLIENT INFORMATION Name Date Address City Zip Phone number Email address Type of work Ethnicity Date of birth What was your hair
More informationMicropigmentation (Semi-Permanent Makeup) Informed Consent
Micropigmentation (Semi-Permanent Makeup) Informed Consent The nature and method of the proposed semi-permanent makeup (cosmetic tattoo) procedure has been explained to me as having the usual risks inherent
More informationRegistration & History Form. Client Name: Date: Address: City: State: Zip: Phone No.: Birthday: Anniversary: How did you hear about us?
Registration & History Form Client Name: Date: Address: City: State: Zip: Phone No.: Email: Birthday: Anniversary: How did you hear about us? Name of person who referred you: Phone: Question Y N Date and
More informationHow did you hear of us? Friend: Our patient: Magazine: Physician referral:
Patient Information Today s Date: Title: Dr. Mr. Mrs. Ms. Name (Last, First, Middle) Gender: M F Age: Birthdate: Social Security: Street Address City, State & ZIP Home Phone Cell Phone Work Phone Email
More informationThe new MÖ Laser Nd Yag 532nm & 1064nm uses the latest generation Pico technology. Powerful trillions of a seconds laser energy to grind the pigment
The new MÖ Laser Nd Yag 532nm & 1064nm uses the latest generation Pico technology. Powerful trillions of a seconds laser energy to grind the pigment in the skin tissue resulting of complete tattoo and
More informationCLIENT QUESTIONNAIRE
CLIENT QUESTIONNAIRE YOUR INFORMATION Name Age DOB Address City State Zip Home Phone Cell Phone Email MEDICATIONS Medication When How Long Medication When How Long Antibiotics Androstendione Accutane Testosterone
More informationPre and Post Procedure Information for Cosmetic Laser Skin Resurfacing with the DOT laser. James A. Rieger, MD (316)
Pre and Post Procedure Information for Cosmetic Laser Skin Resurfacing with the DOT laser James A. Rieger, MD (316)-652-9333 You have scheduled a delicate cosmetic laser procedure. The following information
More informationDermaVisage Step by Step
DermaVisage Step by Step DermaVisage includes both Diamond and Crystal Microdermabrasion as well as Colour Therapy all in one compact machine. Designed to offer the best of both worlds, DermaVisage allows
More informationCOMMON CONTRAINDICATIONS FOR FACIALS
COMMON CONTRAINDICATIONS FOR FACIALS Ms. Wade Cosmetology Department Fullerton College PREVENTION The following conditions cannot receive a facial treatment: Viruses Bacterial Infections Fungal Infections
More informationS Main St, Kaysville, UT 84037
MEDICAL HISTORY Date Name Age Date of birth: Email: Address City State Zip Home Phone Work or CellPhone Preference number for contact (appointment reminders or other) Primary Physician s Name and Number
More informationPre-Treatment Advice and Procedures
Pre-Treatment Advice and Procedures 1) Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear crusty for up
More informationChapter 13: Informed Consent
Chapter 13: Informed Consent At this point, the various methods of rejuvenation, chemical, mechanical, photon and RF based, as well as laser or surgery should be outlined briefly for the patient. If, upon
More informationPhone [850] Fax [850] Web Send s to: Search Millseye to download App Page 1 of 5
I hereby authorize David M. Mills, MD, FACS and/or any assistants as may be appointed to perform the following procedure or treatment: Lumenis Encore Ultrapulse Fractional CO 2 Laser Skin Resurfacing Informational
More informationVICKI HENKE MICROBLADING PERMANENT COSMETICS. What to expect in the healing process for all brow enhancement/permanent makeup procedures.
MICROBLADING/MANUAL PERMANENT MAKEUP TREATMENT BEFORE & AFTER CARE INSTURCTIONS What to expect in the healing process for all brow enhancement/permanent makeup procedures. WHILE YOUR SKIN HEALS, BE PREPARED
More informationPatient Information Leaflet. Dermal Filler
Patient Information Leaflet Dermal Filler When considering treatment with dermal fillers we want you to have a safe treatment. Some risks are unavoidable and out of your control. The following information
More informationCLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Age Have you received chemotherapy
More informationINFORMED CONSENT Juvederm INJECTION
INSTRUCTIONS This is an informed-consent document which has been prepared to help Dr. Jennifer Geoghegan inform you concerning Juvederm (Non-Animal Stabilized Hyaluronic Acid, Allergan Aesthetics) tissue
More informationSOUTH BAY LIPO LIGHT
SOUTH BAY LIPO LIGHT FACIAL TREATMENT INTAKE FORM Your success is our #1 priority. PLEASE ANSWER ALL QUESTIONS Help us to help you achieve success by filling out this questionnaire as completely as possible.
More information