Laser Removal Day Of Appointment Questionnaire
Patient Information
Full Name
*
First Name
Last Name
Date of birth
*
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Month
-
Day
Year
Date
Gender
*
Select
Female
Male
Undisclosed
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):
*
Clear
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
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Month
-
Day
Year
Date
Submit
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