New Client Medical Background Information
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Name *
Date of Birth *
MM
/
DD
/
YYYY
Occupation
Full Address (Street/City/State/Zip) *
Phone Number *
Emergency Contact (Name & Number) *
How were you referred to us? (if Friend, please list their name) *
Which of the following describes your skin type? *
Do you regularly use tanning salons, or sunbathe? *
Have you ever used Acutane? *
If yes, to using Acutane, when was the last time you used it?
Are you currently under the care of a physician? *
If yes, please explain why
Do you have any of the following medical conditions?  Please check all that apply *
Required
Please list any other medical conditions
Have you ever had an allergic reaction to any of the following?  Please check all that apply. *
Required
If you marked yes to any allergic reactions, pleaes describe the reaction here.
What oral medications are currently taking? *
Required
If you chose other, please list:
What topical medications or creams are you using? *
What herbal supplements do you take regulary? *
Are you using any products with Retin-A? *
Are you on mood altering, or anti-depressant medication? *
Have you used any of the following hair removal techniques in the past 6 weeks?  Check all that apply *
Required
Have you had any recent tanning or sun exposure that changed the color of your skin? *
Have you recently used any self-tanning lotions or treatments? *
Do you form thick or raised scars from cuts or burns? *
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? *
If yes, please describe:
Are you pregnant, or trying to get pregnant? (we can not treat while you are pregnant) *
Are you currently breastfeeding? *
I certify that the preceding medical, personal, and skin history are true and correct. I am aware that is it my responsibility to inform the technician, esthetician, therapist, 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. I agree to electronically sign this document by entering my name and date (MM/DD/YYYY), and understand this is in place of a handwritten signature *
I have received the documentation from True Skin (or saw it available for me to read/download on our website), titled "Consent for Laser/Light Based Treatment,"  explaining to me the risks that are involved with any laser treatment and consent to accept treatment *
By signing below, I have read and understand all the information presented to me before consenting to treatment. And I have had all my questions answered. I understand the procedure and accept the risks.  I hereby release Dawn Kalin (individual), True Skin (the facility), and Dr. Steven Kohn (doctor) from all liabilities associated with the above indicated procedure. Please write your name and date (MM/DD/YYYY) *
By signing below, I understand and accept that any appointment that I cancel without proper 24 hour notice, or simply do not show up for may be subjected to a $45 cancellation fee. I also understand that if I am more than 10 minutes late for my appointment, I may need to be rescheduled. And I understand that True Skin can not guarantee the same technician with each appointment. Please write your name and date (MM/DD/YYYY) *
By signing below, I understand that I must not be taking any antibiotics at the time of my treatment.  And that I must wait 10 days from the day I’m finished the medication before I can be treated.  Failure to obey this rule increases the chance of being burned.  *For Fractional and IPL Clients, I understand I must stop using any products containing Retin-A, 4 days before treatment. Please write your name and date (MM/DD/YYYY) *

I understand that with each treatment the laser is killing a small percentage of active hair only. I will need more than 1 package to be hair free. Each person, and each body part, responds differently to laser hair removal, and therefore we are not able to predetermine how many treatments will be needed. By signing below, I am acknowledging I understand the expectation.  Please write your name and date


 (MM/DD/YYYY) *
By signing below, I give consent for True Skin to use my before and after photos in their marketing without compensation. Please write your name and date (MM/DD/YYYY)
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