East Hill Medical Group
|
|
|
- Charlotte Walters
- 5 years ago
- Views:
Transcription
1 Name: of Birth: Address: City: State: Zip: Home Tel. #: Cell #: Employer: Occupation: Emergency Contact: Relationship: Phone: How Referred: Parents Ethnic Background: Previous Treatments Year: Area(s): Other Important Information: Skin Analysis Have you used Retin A in the last 2 weeks in the treatment area(s) Have you had a chemical/acid peel on the treatment area(s) in the last 3 months? Medical History Are you under a doctor s care for anything we should be aware of? If yes, explain Are you currently taking Accutane or have you taken it in the last year? Have you had radiation therapy in the last 6 months? Are you currently on mood altering or depression medication? If yes, please List Have you taken oral antibiotics in the last 14 days? If yes, list: Are you on any light sensitive medications? If yes, list: Other Present Medications, please list Do you take daily aspirin regimen or anti-coagulant? Have you seen a Dermatologist in the past 6 months? If yes, List any Dermatologist strength skin care products being used in the treatment area(s)? Present Herbal Vitamin, IRON and other supplements, please list Do you have excessive hair growth? If yes, list location(s) Are you using a topical antibiotic on the treatment area(s) for acne or other? if yes, list: Do you have metal implants? If yes, list location(s) Do you have any tattoos or body piercing in the treatment area? If yes, where? Have you seen an Endocrinologist in the last year? If yes, explain Are you pregnant? Y N Women Only If so, Due Do you have hypo/hyperactive thyroid condition? If yes, List surgeries and/or medications Hysterectomy? Y N Regular Periods? Y N Heart Condition? Menopause? Over - In - Peri-menopause Birth Control Copper IUD Have you been diagnosed with PCOS (Polycystic Ovarian Syndrome) Have you ever had any of the following? If yes, terminated (t) or continued (c)? Heart Condition ( ) Yes ( ) No Pacemaker ( ) Yes ( ) No Cancer Treatment ( ) Yes ( ) No Hepatitis Type ( ) Yes ( ) No Diabeties ( ) Yes ( ) No Herpes I/II ( ) Yes ( ) No Coagulation Problem ( ) Yes ( ) No Pertinent Allergy ( ) Yes ( ) No Keloids ( ) Yes ( ) No Acne ( ) Yes ( ) No Aloe Allergy ( ) Yes ( ) No I understand that l is not immediately permanent and that a series of treatments are necessary to achieve permanent hair reduction. I understand the success of treatments largely depends on my cooperation with my treatment schedule and recommendations made by the laser technician. I agree to inform the technician of any changes in my skin after treatment as well as changes in my general health. By signing below, I certify the above information to be accurate. Signature : Technician
2 Fitzpatrick Skin Typing Question Score What is your eye color? Light Blue Blue, Grey or Green Blue / Hazel Brown Brownish Black What is the Natural color of your hair? Sandy / Red Blonde Dark Blonde/Light Brown What is the color of your non-exposed skin? Do you have freckles on unexposed areas? What happens the first time you stay in the sun too long? Reddish Very pale Pale with a beige tint Chestnut/Brown Light Brown Black Dark Brown Many Several Few Incidental None Painful, Redness, Blistering, Peeling Blistering, followed by peeling Burns, sometimes followed by peeling Rarely Burns Never Burns To what degree do you turn brown? Hardly or not at all Light color tan Reasonable tan Tan very easily Turn dark brown quickly Do you turn brown after the first several hours of sun exposure Never Seldom Sometimes Often Always How does your face react to the sun? Very Sensitive Sensitive Normal Very Resistant Never had a problem When did you last expose your body to sun, tanning booth or tan crème? When did you last expose the treatment area to the sun? More than 3 month More than 3 month 2-3 months 1-2 months Less than a month 2-3 months 1-2 months Less than a month Total Skin Type Less than 2 weeks Less than 2 weeks Score with tanning habits Skin Total Type We do NOT recommend laser therapy if any of the below conditions exist. Please circle those that apply. Photosensitive disorder Active Herpes in treatment area(s) Active Shingles Seizure disorder triggered by light TYPE 1: Highly sun-sensitive, always burns, never tans. Example: Very pale Caucasian, freckles, or Albino Score 0 7 TYPE 2: Very sun-sensitive, burn easily, tans minimally. Example: Fair-skinned Caucasian 8 16 TYPE 3: Sun-sensitive skin, sometimes burns, slowly tans to light brown. Example: Darker Caucasian, European mix TYPE 4 Minimally sun-sensitive, rarely burns, always tans to moderate brown. Example: Mediterranean, European, Asian, Hispanic, Native American TYPE 5: Sun-insensitive skin, rarely burns, tans well. Example: Hispanic, Afro-American, Middle Eastern Over 30 TYPE 6: un-insensitive never burns, deeply pigmented. Example: Afro-American, African, Middle Eastern Over 30
3 INFORMED CONSENT: PHOTO FACIAL, REMOVAL/REDUCTION OF ROSACEA & SPIDER VEINS PATIENT: I duly authorize EAST HILL LASER & AESTHETICS CLINIC and the certified laser technician to perform this procedure. The light pulsed system may dramatically reduce darkly pigmented sunspots and spider veins. More than one laser session may be necessary to achieve desired results. The FDA has given the clearance for removal of brown spots, spider veins and rosacea. Pigmented Lesions: The skin treated may be red and swollen with fine, thin scabs forming. Keep the treated areas covered with post procedure lotion recommended by the doctor or Aesthetician until the thin scabs fall off. This process will take anywhere from 1 to 3 weeks. We are unable to treat clients that are currently taking ACCUTANE and PHOTOSENSITIZING medications, such as antibiotics, and patients using ANTICOAGULANTS. Please inform the doctor or aesthetician prior to your treatment. THE FOLLOWING PROBLEMS MAY OCCUR WITH TREATMENT: 1. Scarring: The light pulsed system can create a bruising and moderate burn or blister of the skin. For an effective treatment, the power (joules) needs to be just below the blistering point, which means the skin will be red. There is a risk of scarring. 2. Hyper-Pigmentation (browning) and Hypo-Pigmentation (whitening) have been noted after treatment, especially with a darker complexion. This usually resolves within weeks, but can take as long as 3 to 6 months in some cases. Permanent color change has occurred in rare cases. If you have a lot of color in your skin, a lightening cream may be recommended to reduce the melanin in your skin before the treatment. Avoiding sun exposure after the treatment is crucial to reducing the risk of color change. 3. Infection: Although infection following pulsed light treatment is unusual, bacterial, fungal and viral infections can occur. Herpes Simplex Virus infections around the mouth can occur following the laser treatment. This applies to individuals with a past history of herpes simplex virus infection in the mouth area. Should any type of skin infection occur, additional treatment including antibiotics may be required. We recommend preventative therapy if you have a history of herpes simplex virus in the treated area. 4. Bleeding: Pinpoint bleeding is rare but can occur following brown spot required. 5. Skin Tissue Pathology: Energy directed at the skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible. Only clearly benign pigmented lesions can be treated. Check with your doctor for clearance for the treatment. 6. Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. Systemic reactions (which are more serious) may result from prescription medicines. Allergic reactions may require additional treatment.
4 Photo Facial/Skin Rejuvenation Pre-Treatment Instructions It is crucial to the health of your skin and the success of your Photo Facial that these guidelines be closely followed: Patients should NOT be treated with the following: Active cold sores or warts Open wounds or lesions Sunburn Excessively sensitive skin Dermatitis, Psoriasis or Eczema Untreated skin cancer in treatment site Permanent makeup in treatment site Rashes, allergies or sensitive skin reactions Accutane use within the past 12 months Radiation or chemotherapy in the past 12 months Pregnant or breastfeeding Antibiotic use 14 days prior to treatment Two weeks PRIOR to your treatment you should avoid: Electrolysis, waxing, depilatory creams Laser or treatments Chemical peel or microdermabrasion treatment Retin-A, Renova, Differin, Tazorac Products containing Retinol, AHA, BHA or Benzoyl Peroxide Exfoliating products that may be drying or irritating Sun exposure or sunburn Sunless tanning If you have any history of Herpes Simplex, please notify the Aesthetician BEFORE receiving Photo Facial treatments. Please call us at if you should have any questions regarding preparation for your Photo Facial Other Policies - Cancellations and rescheduling of appointments require a 24-hour notice to avoid forfeiting a treatment. Missing an appointment will be considered a No Show and that treatment will be forfeited. Please call to reschedule your appointment.
5 Photo Facial/Skin Rejuvenation Pre-Treatment Instructions It is crucial to the health of your skin and the success of your Photo Facial that these guidelines be closely followed: Patients should NOT be treated with the following: Active cold sores or warts Open wounds or lesions Sunburn Excessively sensitive skin Dermatitis, Psoriasis or Eczema Untreated skin cancer in treatment site Permanent makeup in treatment site Rashes, allergies or sensitive skin reactions Accutane use within the past 12 months Radiation or chemotherapy in the past 12 months Pregnant or breastfeeding Two weeks PRIOR to your treatment you should avoid: Electrolysis, waxing, depilatory creams Laser or treatments Chemical peel or microdermabrasion treatment Retin-A, Renova, Differin, Tazorac Products containing Retinol, AHA, BHA or Benzoyl Peroxide Exfoliating products that may be drying or irritating Sun exposure or sunburn Sunless tanning If you have any history of Herpes Simplex, please notify the Aesthetician BEFORE receiving Photo Facial treatments. Please call us at if you should have any questions regarding preparation for your Photo Facial Other Policies - Cancellations and rescheduling of appointments require a 24-hour notice to avoid forfeiting a treatment. Missing an appointment will be considered a No Show and that treatment will be forfeited. Please call to reschedule your appointment. PATIENT COPY Please Keep
East 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):
Welcome 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
Hair 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
HEALTH 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:
Laser 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.
Chameleon 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:
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
Intake 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
Informed 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,
HISTORY CARD. [ ] Face: Nose [ ] Face: Sideburns [ ] Glabella [ ] Gluteal [ ] Hands & Feet
![HISTORY CARD. [ ] Face: Nose [ ] Face: Sideburns [ ] Glabella [ ] Gluteal [ ] Hands & Feet](/thumbs/77/74907590.jpg "HISTORY 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:
AREA 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
INFORMED 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
HEALTH 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
Client 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)
Imbue 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
CLINICAL 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
CLEAR 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:
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
Informed 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
Alani 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
513 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
CLIENT 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
Brilliant 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,
5504 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
Contact 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
Welcome 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
Beautiful 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
Client 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
CLIENT 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
Maya 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
513 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:
Date: 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
CLIENT 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
Touch 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.
Newport 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
Areas 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.
Laser Services New Patient Packet
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
SKIN 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
IPL 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
NEW 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:
NEW 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:
Forename 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
Pre 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
Laser 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
Aesthetic 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
Client 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
Microblading 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
Client 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
Client 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
Medication 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:
Everything you need to know about TATTOO REMOVAL
Everything you need to know about TATTOO REMOVAL LASER TATTOO REDUCTION Tattoos are meant to last forever, but sometimes it would be good if they didn t! Whether you wish to erase a mistake or fade a tattoo
Patient 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:
patient 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
COSMETIC 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
New 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:
STATEMENT 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
Client 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
LASER 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.
Permanent 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
Consultation 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
COMMON 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
SkinCeuticals 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
Client 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
Massey 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.
PRODUCT 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
Consent 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
CLIENT 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:
S 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
GENERAL 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
Pre- & 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.
COSMETIC 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
Consultation 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
SOUTH 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.
Timeless 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
Microblading 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
Contraindications Pre and Post Instructions
Contraindications Pre and Post Instructions **VERY IMPORTANT---PLEASE READ** **It is very important you follow these rules as medical conditions can affect the outcome of your eyebrows. Please notify me
VENUS BEAUTY LOUNGE. Before Your Microblading Session
Great microblading is not a beautiful result directly after treatment. It is a crisp, natural, long-lasting result once healed. Aleksandra Maniuse-Founder Deluxe Brows Microblading is a manual technique
(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
Brow 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
Permanent 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
SALIBIAN 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
Elite Beauty Essentials
Elite Beauty Essentials P E R M A N E N T M A K E U P W I L L N O T B E PERFORMED IF YOU ARE PREGNANT, NURSING or TRYING!!! NO EXCEPTIONS! If you are late for your appointment you will be rescheduled.
Client Consultation. Date of Birth: Address: Home Phone: ( ) Business Phone: ( ) Referred by:
Client Consultation Date: Name: Date of Birth: Address: Home Phone: ( ) Business Phone: ( ) Cell Phone: ( ) E-mail address: Married: Single: Employer: Occupation: Does your job require that you work outdoors?
Q-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
ibrow Studio Client Information Packet
ibrow Studio Client Information Packet Thank you so much for trusting me with your beautiful face! Prior to booking an appointment, we ask that all ibrow Studio clients read and review the information
Client 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
VICKI 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
IPL 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
COLORADO 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
Informed 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
Pre 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
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy
APPOINTMENT POLICY. Dear Client, Your time is very important to me and I appreciate that you equally respect mine. Below is our appointment policy.
APPOINTMENT POLICY Dear Client, Your time is very important to me and I appreciate that you equally respect mine. Below is our appointment policy. 1. One consultation visit is free of charge. A 24 hour
please complete the following:
Page 1 of 7 PLEASE NOTE: 1. All sections of this form must be CLEARLY PRINTED in detail to prevent delays. The inability to read the report will result in delays. 2. Please attach clear photos of the affected
Last Name: First Name: Address: Apt: City: State:
Today s date: Estimated Weight Height Last Name: First Name: Address: Apt: City: State: Zip Phone: (H): (C) (W) Email: Please note, email will not be given to others and will only used for reminders and
TREATMENT GUIDELINES. September 2012 D0592 Rev. B Cutera 3240 Bayshore Boulevard Brisbane California PH:
TREATMENT GUIDELINES September 2012 D0592 Rev. B Cutera 3240 Bayshore Boulevard Brisbane California 94005 PH: 415.657.5500 www.cutera.com Pearl Treatment Guidelines The following guidelines are based on
How 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
Menter 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
12 FEBRUARY 2016 LNEoNLiNE.com
12 FEBRUARY 2016 LNEoNLiNE.com Delicate DEALINGS UNDERSTANDING SENSITIVE SKIN BY KRIS CAMPBELL S ensitive skin is a condition the skin care professional sees every day in the treatment room. In a study
Permanent Makeup Before & Aftercare Instructions. Permanent Makeup by Michelle Louise
Permanent Makeup by Michelle Louise Permanent Makeup Before & Aftercare Instructions IMPORTANT INFORMATION This document contains important information. Please read it carefully. www.michelle-lousie.com