Laser Removal Day Of Client Appointment Form

Laser Removal Day Of Appointment Questionnaire

Patient Information
Full Name *

First Name Last Name
Date of birth *

Month Day Year
Date
Gender *
Phone Number *

Area Code Phone Number
I agree to let Laser Flavor and Flavor Beauty Bar LLC take treatment site photos/videos for promotional and social media purposes. Please Sign Below (no explicit photos will be posted, this is optional for clients before December 2020): *

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Do You Want To Add Additional Treatment Sites: *

No Thanks Unibrow Lip Chin Neck Scrotum Face Arms Thighs Fingers Chest Areola Lower legs Middle Abdomen Underarms Back Feet Buttocks Bikini Labia Toes Happy trail Butthole
Laser Hair Removal Treatment Questionaire
Have you been on any antibiotics and/or sun sensitive medications in the past two week? This includes any medications that have a contraindications laser treatments.

Yes No
Have you had any long term sun exposure in the past 4 weeks?

Yes No
Are you pregnant and/or breastfeeding?

Yes No
Are you going to have any long term sun exposure in the upcoming weeks?

Yes No
Have you used any sunless tanner in the past 2 weeks on the area that we will be treating today? It is important that you do not have any sunless tanner residue on your skin because this will lead to a pigment issue.

Yes No
Have you used any prescription creams on the area of the body being treated today? Retin A, Renova, Tretinion, Avita, Alustra, Adapalene, Avage, Differen, Tazorac, Tazarotene, etc.

Yes No
Have you waxed, tweezed, threaded, or used depilatories on the treatment area within the past 5 weeks?

Yes No
Do you have any makeup and/or deodorant and/or lotions on any of the areas we will be treating today?

Yes No
Do you have any of the following hair color(s) in the area(s) being treated? Grey, white, blonde, strawberry blonde, light brown.

Yes No
Do you have any tattoos on the areas being treated? If yes please take full responsibility of making the technician aware of the tattoos.

Yes No
I agree that I read and fully understand this entire consent form and I am of sound, mind, and fully capable of executing this waiver for myself.

I Agree
I have read and completed the this form in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that may be caused by the laser.

I Agree
By checking this box I agree to and have read and agree to the legal agreement above.

I Agree
Legal Signature

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Date

Month Day Year
Date
Should be Empty:

Laser Removal Day Of Appointment Questionnaire

Laser Hair Removal Treatment Questionaire