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: Please list any mood altering/depression medications: Please list all present medications: Please list all herbal and vitamin supplements: Please list any allergies (ex. Latex, Medications, Lidocaine, Foods): (Cell) How Referred: Previous Treatments: Yes [ ] No [ ] If yes, date Last Treated: / / Area: What are your parents ethnic backgrounds? WOMEN ONLY. MEN SKIP TO NEXT SECTION Are you pregnant: Yes [ ] No [ ] If yes, due date: / / Regular periods: Yes [ ] No [ ] Over/In Menopause: Yes [ ] No [ ] Breast Implants: Yes [ ] No [ ] Hysterectomy: Yes [ ] No [ ] Birth Control: Yes [ ] No [ ] Polycystic Ovarian Syndrome: Yes [ ] No [ ] HAVE YOU EVER HAD ANY OF THE FOLLOWING? IF YES, TERMINATED [T] OR CONTINUED [C]? Heart Condition: Yes [ ] No [ ] Cancer Treatment: Yes [ ] No [ ] Diabetes: Yes [ ] No [ ] Coagulation Problem: Yes [ ] No [ ] Herpes I/II: Yes [ ] No [ ] Pacemaker: Yes [ ] No [ ] Hepatitis (Type ): Yes [ ] No [ ] HIV: Yes [ ] No [ ] Keloids: Yes [ ] No [ ] WHERE ARE YOU INTERESTED IN GETTING LASER HAIR REMOVAL? [ ] Abdomen [ ] Areola [ ] Arms [ ] Back [ ] Bikini [ ] Chest [ ] Ears [ ] Face: Chin [ ] Face: Full [ ] Face: Lip [ ] Face: Nose [ ] Face: Sideburns [ ] Glabella [ ] Gluteal [ ] Hands & Feet [ ] Legs [ ] Neck [ ] Shoulders [ ] Underarms ARE YOU INTERESTED IN ADDITIONAL SERVICES OR TREATMENTS? [ ] Laser Acne Treatment [ ] Photo Facials [ ] Fine Lines & Wrinkles Treatments [ ] Skincare Treatments [ ] Ultherapy [ ] ELOS Sublative RF Skin Rejuvenation [ ] Facial & Leg Vessel Treatments [ ] Lipo Light & Body Contouring [ ] Injectables [ ] PRP Platelet Rich Plasma [ ] CryoClear Skin Tag, AK, and Age Spots Removal I understand that laser hair removal is not immediately permanent and that a series of treatments are necessary to achieve permanent hair reduction. I understand the success of treatments depends largely 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. Print Name: Technician: Signature: Date:
FITZPATRICK SKIN TYPING SKIN TYPE I Never tans, always burns (extremely fair skin, blonde/red hair) SKIN TYPE II Occasionally tans, usually burns (fair skin, sandy to brown hair, green/brown eyes) SKIN TYPE III Often tans, sometimes burns during first exposure to sun (medium skin, brown hair) SKIN TYPE IV Always tans, never burns (olive skin, brown hair) SKIN TYPE V Never burns (dark brown skin, black hair) SKIN TYPE VI Never burns (black skin, black hair) We do NOT recommend laser therapy if any of the below conditions exist. Please check any box that describes your current health condition. Please advise the technician of any medications you are taking (see form). Photosensitivity Disorder Herpes (active) Shingles (active) Seizure disorder triggered by light SCORE 0 1 2 3 4 What is your eye color Light Blue Blue, Grey or Green Blue/Hazel Brown Brownish Black Scores What is the natural color of your hair Sandy/Red Blonde Dark Blonde/Light Brown Chestnut/Brown Black What is the color of your non-exposed skin Reddish Very Pale Pale with beige tint Light Brown Dark Brown Do you have freckles on unexposed areas Many Several Few Incidential None What happens the first time you stay in the sun too long Painful, Reddness, 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 TOTAL SKIN TYPE When did you last expose your body to sun or tanning booth or tan creme More than 3 months 2-3 months 1-2 months Less than one month Less than 2 weeks When did you last expose the area to be treated to sun More than 3 months 2-3 months 1-2 months Less than one month Less than 2 weeks Skin Type Score Fitzpatrick Skin Type 0-7 I 8-16 II SCORE WITH TANNING HABITS TOTAL SKIN TYPE 17-25 III 25-30 IV Over 30 V - VI Client Signature Date
SKIN ANALYSIS Have you used Retin A in the last week in the area to be treated? Are you currently taking Accutane for acne, or have you taken it in the last 6 months? If yes, explain: Have you had a chemical or acid peel on your face in the last 3 months? If yes, where and when and what percent? Have you seen a Dermatologist in the past 6 months? If yes, are you using Dermatologist strength skincare products? List products: Are you currently using a topical antibiotic on your face for acne? Have you taken oral antibiotics in the last two weeks? Do you have any tattoos, permanent makeup, or body piercings in the area to be treated? Where? Have you had any injectables in the treatment area in the last 6 months? (ie. Juvéderm, botox, Restylane) Do you have excessive hair growth? If yes, in what areas on the body? Do you have a hypo/hyperactive thyroid condition? If yes, have you had surgery or taken medication for the condition? Have you seen an Endocrinologist in the last year? If yes, explain: Have you tried laser hair removal or other methods of hair removal in the past? If yes, explain: Client Signature: Date:
(Page 1 of 2) Client Signature: Date: HAIR REMOVAL CONSENT FORM I authorize Anti-Aging Centers of Connecticut, LLC and its designated staff to perform Laser Hair Removal on my body. I understand that Laser Hair Removal is an FDA-approved treatment method for removing unwanted hair. I have been advised of the possible adverse reactions as well as the Pre-, Intra- and Post-treatment care which are as follows: PAIN The Laser causes mild discomfort which can be minimized by applying an anesthetic cream approximately one hour prior to each treatment. CRUSTING If superficial crusts form, they should resolve with the gentle care we describe in the aftercare instructions. EYE PROTECTION Protective eye wear must be warn by everyone present during treatments. PIGMENT CHANGES Temporary color changes such as hyper pigmentation, which is a brown discoloration, or hypo pigmentation, which is a skin lightening, my occur. While these can take 3 to 6 months to resolve, they rarely lead to permanent scarring (less than 1%). PERSISTENCE OF HAIR Evaluation of Laser Hair Removal is on going, but studies and clinical experiences suggest that multiple treatments produce long-term hair loss. Although some clients respond better than others, most clients will experience progressive hair loss with each treatment. PRE-TREATMENT INSTRUCTIONS: 1. Avoid the sun: - 7-14 days before and after YAG treatments (Tan Skin & Dark Skin) - 4-6 weeks before and 1 week after GentleLASE Alexandrite treatment (Light Skin with no tan) 2. You MUST avoid bleaching & self tanners for 1 week, and avoid plucking or waxing hair for 2 weeks prior to treatment. 3. If you have a history of perioral herpes, prophylatic antiviral therapy may be started the day before treatment and continued 1 week after treatment. 4. The use of tanning cream, bleach, or Nair must be discontinued at least 1 week before treatment. Avoid antibiotics prior to treatment for 1-2 weeks to avoid photosensitivity. For clients treating their face, please discontinue Retin A for at least 1 week, no Accutane in prior 6 months, no injectable filler for 4 weeks prior to treatment, and no Botox 1 week before and 1 week after. 5. The laser seeks melanin and is attracted to dark colors. Please wear white or light colored undergarments if you are treating your bikini area. 6. Tanned skin can be treated with the GentleYAG laser but avoiding direct exposure to the sun or tanning beds in the treatment area is always recommended for at least one week before and after treatments. 7. Skin should be free of all products: makeup, deodorant, creams, oils, etc. INTRA-TREATMENT CARE: 8. The skin is cleaned and shaved or left with one day of new growth. Use of the topical anesthetic Lidocaine is optional for discomfort. 9. Epidermal melanocytes compete as the chromophore (target) for the 755 or 1064 nm wavelength with melanin at the target site. The DCD, or cooling device, will be used with the laser to minimize epidermal damage. 10. Safety considerations are important during the laser procedure. Protective eye wear will be worn by the client and all personnel during the procedure. Fairfield: (203) 256-0095 2324 Post Rd. Fairfield CT 06824 West Haven: (203) 848-1484 764 Campbell Ave. Suite F, West Haven CT 06516 Port Chester (914) 937-1100 163 North Main St., Port Chester, NY 10573 After Hours: (203) 887-1237 www.aacofct.com
(Page 2 of 2) POST-TREATMENT CARE: 1. Immediately after treatment, there should be erythema (redness) and edema (swelling) at the treatment site which may last from 15 minutes to 24 hours. The erythema may last up to 2-3 days. The application of ice during the first few hours after treatment will reduce the discomfort and swelling that may be experienced but we recommend only aloe vera gel or Dermalogica AfterSun after treatment. Rarely, minor epidermal blistering may occur in which case polysporian cream may be applied. If this should happen, please contact our office immediately and our nurse will give you further instructions. 2. Makeup may be used immediately after treatment unless there is epidermal blistering. It is recommended to use ONLY NEW makeup to reduce the possibilities of infection (Folliculitis). 3. Avoid sun exposure to reduce the chance of hyper pigmentations or darker pigmentation for 7 days post treatment. Use sunscreen (SPF 30 or greater) at all time throughout the course of treatment. 4. Avoid picking or scratching of the treated skin. If you are experiencing itchy skin, apply 1% hydrocortisone cream or Dermalogica AfterSun as needed to avoid irritation. Do not use any other hair removal treatment products or similar treatments (waxing, electrolysis or tweezing) that will disturb the hair follicle on the treatment area for a minimum of 2 weeks after the treatment is performed. Shaving may be performed. 5. Call our office with any questions or concerns you may have after the treatment. Return to our office or call for appointment at the first sign of the return of hair growth. This can mean within 4-6 weeks for the upper body treated and possibly as long as 4-12 weeks for the lower body. Hair regrowth occurs at different rates on different areas of the body. New hair growth will not occur for at least three weeks after treatment 6. Anywhere from 5-21 days after the treatment, shedding of the surface hair may occur and this appears as new hair growth. This is not new hair growth. You can clean and remove the hair by washing or wiping the area with a wet cloth or loofa sponge. 7. After the underarms are treated, avoid reapplying deodorant for 30+ minutes to avoid irritation. 8. There are no bathing restrictions except to treat the skin gently. For 48 hours: No scrubbing, rubbing or harsh products; treat as if you had sunburn. We recommend Dermalogica Clearing Wash to cleanse the area for 48 hours. The product clears bacteria and normalizes the ph of the skin. 9. Exercise is not recommended for the first 24 hours after treatment to avoid irritating follicles. I acknowledge that I have read the adverse reactions above and I feel that I have been adequately informed of the risks of Laser Hair Removal treatments. Before each treatment I will inform the Laser Technician if I have taken any new medications since my last treatment or if I have tanned the areas to be treated either by sunlight or artificially. I understand that recently tanned skin should only be treated with the YAG Laser and only after being out of the sunlight, tanning beds and/or the use of tanning creams for a minimum of 7 days. I also understand that some medications can make my skin photosensitive and either of the aforementioned conditions could cause the Laser to damage my skin. I consent to the taking of photographs during the course of my therapy for the purpose of medical education. I understand that my identity will not be revealed on the photographs or corresponding text. I also agree to comply with the recommended aftercare guidelines which are crucial for healing, prevention of scarring and hyper pigmentation. I agree to cooperate with the recommendations of Anti-Aging Centers of Connecticut, LLC, and I realize that any lack of cooperation could result in less than optimum results. I certify that I have read and fully understood this form and consent to the procedures referred to in this document. I have had the opportunity to ask Anti-Aging Centers of Connecticut, LLC any questions regarding the proposed treatment. I also certify that I read and write English. By signing below, I acknowledge that I have read and understand all information presented to me before signing this consent form. I hereby release Anti-Aging Centers of Connecticut, LLC, its medical staff and technicians from any liability arising out of the services associated with the above treatment. Client Signature: Technician Signature: Date: Date: I have received a copy of the Consent & Client Instructions. Client Signature: Date: Fairfield: (203) 256-0095 2324 Post Rd. Fairfield CT 06824 West Haven: (203) 848-1484 764 Campbell Ave. Suite F, West Haven CT 06516 Port Chester (914) 937-1100 163 North Main St., Port Chester, NY 10573 After Hours: (203) 887-1237 www.aacofct.com
CANCELLATION/NO SHOW POLICY AAC understands that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another client from getting their much needed treatment. Conversely, the situation may arise where another client fails to cancel and we are unable to schedule you a visit, due to a seemly full appointment book! If an appointment is not cancelled at least 24 hours in advance you will be charged a $25 fee LATE CANCELLATIONS A late cancellation is considered when a client fails to cancel their scheduled appointment with a 24 hour advance notice. NO SHOW POLICY A no-show is someone who misses an appointment without cancelling it with a 24 hour advance notice. A failure to be present at the time of a scheduled appointment will be recorded in your permanent profile record as a NO SHOW. *First missed appointment: there will be no charge CREDIT CARD ON FILE POLICY At AAC, we require keeping your credit card or debit card on file as a convenient method of payment for no show fee. Your credit card information is kept confidential and secure and the $25 cancellation fee will only be processed if AAC is not given the 24 hour notice as stated above. AAC will call to let you know of your missed appointment and that 24 hours after the missed appointment AAC will process the credit card authorized on file to be charged. If you have any questions or dispute please call within the 24 hours of missed appointment. I authorize AAC (Anti Aging Centers of Connecticut, LLC) to charge $25 for a no show of my scheduled appointment 24 hours after the appointment to my credit card or debit card on file. I, the undersigned, authorize and request AAC to charge my credit card on file $25 for a no show fee and agree this is my financial responsibility. This responsibility only relates to a missed appointment (no show fee). Cardholder Name Cardholder Signature Fairfield: (203) 256-0095 2324 Post Rd. Fairfield CT 06824 West Haven: (203) 848-1484 764 Campbell Ave. Suite F, West Haven CT 06516 Port Chester (914) 937-1100 163 North Main St., Port Chester, NY 10573 After Hours: (203) 887-1237 www.aacofct.com