Laser Hair Removal Consultation – Padra Registration

Laser Hair Removal Consultation Form

PATIENT INFORMATION

Full Name *

Date of Birth *

Address *

Email *

Cell phone *

Secondary Phone *

SKIN AND HAIR DETAILS

Skin Type (Fitzpatrick Scale): *

Hair Color: *

Black

Brown

Light

Colorless

Hair Thickness: *

Thick

Medium

Thin

Area(s) of Concern: *

Face

Legs

Hands

Bikini

Underarms

Half Legs

Half Hands

Beard Lines

Nape

Around Breast

Chest

Back

Buttocks

Full Bikini (Male)

Neck

MEDICAL HISTORY
Area(s) of Concern: *

Keloids

Excessive Scarring

Cold sore

Genital Herpes

Lymphedema

Active Acne

HPV

HIV

Infection

Hepatitis

Eczema

Dermatitis

Rashes

Epilepsy

Vitiligo

Pregnancy

Lactation

Crohn’s Disease

Hyperthyroidism

Psoriasis

Hormonal disorders

Anticoagulants Therapy

Autoimmune disease such as Lupus

Menstrual disorders

Active Sunburn/Taning

Melanoma or Lesions suspected Malignancy

MEDICINE *

Isotretinoin (Roaccutane) (If “Yes” how long have you been using it?)Isotretinoin (Roaccutane) (If “Yes” how long have you been using it?)

Topical Medication (If “Yes” which medicine?)Topical Medication (If “Yes” which medicine?)

Antibiotics (If “Yes” which medicine?)Antibiotics (If “Yes” which medicine?)

Do you take any special medicine? (If “Yes” which medicine?)Do you take any special medicine? (If “Yes” which medicine?)

HAVE YOU RECENTLY:
Aesthetic: *

Fillers

Injectables

Laser Treatments

Had any recent exfoliation: *

Mechanical

Chemical

Moroccan bath

EXPECTATIONS AND GOALS *

Are you aware of the potential side effects and risks? *

Yes

CONSENT AND UNDERSTANDINGS

Have you received information about the procedure and its process? *

Yes

Do you understand the importance of sun protection during and after treatment? *

Yes

All of the information is true and accurate to the best of my knowledge.

Patient Signature *

Clear

Witness Name *

Clear

If you are human, leave this field blank.