CLIENT INFORMATION & MEDICAL HISTORY
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.
PERSONAL HISTORY
Client Name ______________________________________________
 Today’s Date ________________ Date of Birth	    ______________	Age		
Occupation						(for post treatment aftercare instruction)
Home Address__________________________City_______________ State____Zip ________
Home Phone (   	  )				         
Cell Phone (____)				
Email Address _______________________________

Emergency Contact Name and Phone___________________________________________________________________________________			
How did you hear about us?     Please circle one    

INTERNET SEARCH  (Google  /  Yahoo  /  MSN):  

Search Term Used: __________________________________    DRIVE-BY         T.V. commercial  	Truck

REFERRED BY: ___________________________	

OTHER: _______________________

Which of the following best describes your skin type? (Please circle one type number)
		  I	 Always burns, never tans		IV	Rarely burns, always tans
		 II	 Always burns, sometimes tans		V	Brown, moderately pigmented skin
		III	Sometimes burns, always tans		VI	Black skin

How old is your tattoo?	___________________________    Is it homemade or professional? ____________________________	                                                                                                                  

MEDICAL HISTORY
Are you currently under the care of a physician?  qYes  q No	If yes, for what:						
Are you currently under the care of a dermatologist?  qYes  qNo      If yes, for what:___________________________________________
Have you ever had a reaction to a previous laser treatment, heat treatment or radiation therapy?   qYes  qNo
Do you have any of the following medical conditions? (Please check all that apply)
qCancer   qDiabetes   qHerpes   qArthritis  qFrequent cold sores   qHIV/AIDS    qKeloid scarring   qSkin disease/Skin lesions  qSeizure disorder   qHepatitis  qBlood clotting abnormalities   qAny active infection
Do you have any other health problems or medical conditions? Please list: _____________________________________________________

MEDICATIONS
What oral medications are you presently taking?   Please List: _______________________________				
Have you ever used Accutane? (used for acne)  qYes   qNo, If yes, when did you last use it?	_________________________________
What topical medications or creams are you currently using?  q Retin-AÆ  qOthers (Please list): 		___________________________

Have you ever had an allergic reaction to any medication? Please List: _______________________________		_________	

HISTORY
Do you currently have a sunburn? qYes   qNo
Do you form thick or raised scars from cuts or burns?   qYes   qNo
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?   qYes   qNo   If yes, please describe: 								
For our female clients:
Are you pregnant or trying to become pregnant?   qYes  qNo    Are you breastfeeding?  qYes qNo	Are you using contraception?   qYes   qNo
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, doctor or nurse of my current medical or health conditions and to update this history.  A current medical history is essential for the caregiver to execute appropriate treatment procedures.

Signature			 Date:			

Would you be interested in receiving emails about out upcoming specials, products, and other laser treatments? Please mark all that apply:

_____ LED Teeth Whitening	_____ Laser Hair Removal 

_____ Photo Facials	_____ Vein Treatments

_____ Medical Grade Skin Care Products	_____ Botox