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LASER HAIR REMOVAL CONSULTATION FORM
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Email
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Your email
Name
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Phone Number
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Date of Birth
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Emergency Contact
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Address
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Gender
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Other:
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Known Allergies (if none leave blank)
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Medical History
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Acne
Active Infection
Anaphylaxis
Lesions, Open wounds
Lupus
Pacemaker
Hirsutism
HIV/AIDS
Hypo/Hyper Pigmentation
Arthritis
Autoimmune Disease
Bell's Palsy
Photosensitivity
Polycystic Ovaries
Poor Blood Circulations
Hysterectomy
Implantable Defibrillator
Irregular Periods
Bleeding Disorders
Breathing Problems/Disease
Cold Sores (HSV1)
Pregnant
Psoriasis
Shingles
Keloid Scarring
Low/High Blood Pressure
Menopause
Liver/Kidney Dysfunction
Diabetes
Eczema/Rashes
Skin Cancer
Thyroid Imbalance
Vitiligo
Epilepsy/Seizures Multiple Sclerosis/ALS Warts
Other Conditions?
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If you have other medical conditions please explain
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Are you currently under a doctor’s care?
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No
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Have you ever been treated for cancer?
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No
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Do you have any implants?
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No
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Have you ever been treated with hormone medication?
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No
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Have you had any severe reactions to histamines?
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No
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Have you had any previous surgeries?
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No
Do you have any allergies?
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If you answer yes to any of the previous medical condition, surgeries or allergies questions please explain below
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List all medications you take, including vitamins, herbal supplements, aspirin, hormones and topical:
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When is your next menstrual cycle due to begin?
(For your comfort, allow five days for your menstrual cycle. Avoid hair removal two days before your cycle is due and two
days after it is completed.)
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Are you pregnant, trying to become pregnant or nursing?
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Maybe
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