Laser Hair Removal, IPL & Vein Therapy Intake Form

Laser Hair Removal, IPL & Vein Therapy Intake Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
What is your gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact

First NameLast Name
Relationship
Emergency Contact Phone Number

Area CodePhone Number
Health Questionnaire: Any existing or recent health conditions?

YesNo
If yes, please list add details:
Any hospitalization/surgery?

YesNo
If yes, please add details:
Any medications?

YesNo
If yes, please add details:
Do you have any medication intolerances?

YesNo
If yes, please add details:
Have you had previous esthetics procedures in the treatment area?

YesNo
If yes, please add details:
Please elaborate on what your expectations from the treatment are: (example: "I want to get rid of my hair from my legs" or "I want to get rid of my sunspots on my face".
Which of the following conditions applies to you?

Under 18 years of age.Pacemaker, defibrillator, or any other implanted electronic device.Any other types of implants in the treatment area.Pregnant or nursingHistory of cancer, especially skin cancer, or pre-malignant moles.Suspicious undiagnosed skin lesions.Diseases such a lupus, erythematosus, porphyria, or epilepsy that may be stimulated by light, or a history of such diseases.Diseases stimulated by heat, such as recurrent herpes simplex (these areas may be treated only following a prophylactic regime).Impaired immune system due to immunosuppressive diseases of any kind.Poorly controlled endocrine disorders, such as uncontrolled diabetes.History of skin disorders, keloids, or abnormal wound healing.History of abnormal bleeding, thrombosis, or coagulopathy.Any surgical procedure in the treatment area within the last 3 month or that is not completely healed.Any kind of wrinkle-filing/Botulinum toxin procedures within the last three months. Treatment should not be performed on permanent fillers.Any active condition such as sores, psoriasis, eczema, or rash in the treatment area.Use of medications and herbs known to induce photosensitivity, such as Isotretinoin (Accutane) within the last 6 months, tetracyclines, or St. John's Wort within the last 2 weeks.Laser resurfacing, micro-needling, or deep chemical peeling in the treatment area within the last 3 months.Tattoo or permanent makeup in the treatment area.Very dry or fragiile skin.Excessively tanned skin from the sun, tanning beds or tanning creams within the last 4 weeks.None of the above.
Do you use immunosuppressive medications? If yes, please specify:
Do you use anticoagulants? If yes, please specify:
Any other condition that is not specified above and may make the treatment unsafe(as per practitioner's discretion). If yes, please specify:
PLEASE READ THE FOLLOWING INFORMATION AND ACKNOWLEDGE THAT YOU UNDERSTAND AND ACCEPT ALL PROVISIONS MENTIONED IN THIS DOCUMENT

- About the Alpha treatments
The Alpha treatments are based on Laser and IPL (Intense Pulsed Light) technologies. Laser and IPL are common phototherapy procedures which are used for a wide range of treatment indications, including hair reduction, pigmentation reduction, general skin rejuvenation, reduction of vascular lesions, acne reduction, and more.

These procedures involve the application of concentrated light energy pulses onto the skin. The light energy is absorbed by different components within the tissue and converted into thermal energy. The heat that is generated during the procedure can damage the target without harming the surrounding healthy skin and can therefore reduce the appearance of the lesion/s.

Since the treatment is based on generating heat within the skin, some mild to moderate discomfort is expected during the treatment. Local erythema (redness) and edema (swelling) are common and

expected reactions immediately after the treatment, and should resolve spontaneously within a few hours.

- About the healing process
The skin begins to heal itself by using its natural repairing mechanisms as soon as the treatment ends. It is important to allow the skin to heal without interference, and avoid any activity which may impair the healing process between treatment sessions. During healing, some skin crusts and scabs are expected to form as the skin works to expel damaged tissue and replace it with new, fresh skin. Do not scratch the scabs! The scabs are expected to peel-off naturally within a few weeks.

- Post-treatment instructions
To alleviate discomfort immediately after the treatment, a cold compress may be applied onto the treatment area, followed by lenitive cream with soothing properties authorized by the treating clinician.

For the first 48 hours after the treatment, avoid sun/UV exposure, hot showers, hot tubs, saunas, intensive exercise, swimming, restrictive clothing which may cause friction with the treatment area, and avoid any perfume, lotion, or other skincare products which are not authorized by the treating clinician.

Throughout and even after the treatment protocol, you should avoid sun/UV exposure, unauthorized skincare, and any unnecessary contact with the treatment area. Apply high-potency sunscreen as needed. Ask your treating clinician for a detailed aftercare plan, including recommendations for sunscreen, and follow it closely to maximize treatment results and minimize the risk of complications.

- Possible side-effects
Complications and prolonged side-effects following Alpha treatments are rare, but possible. These may include:

Excessive irritation, redness, or swelling for about 2-3 days after the treatment.
Change in pigmentation which could last for a few months (more common with darker skin tones).
Breakouts such as acne and cold sores.
Allergic reaction such as hives.
Folliculitis (inflammation in the hair follicle).
Blisters, superficial burns, and scarring (exceedingly rare).
Consent for Treatment

Please read the information below carefully and ask if there is anything that you do not understand. Once completed, please sign and date the form below.

I hereby declare my consent for Alpha Laser/IPL treatments, as described in this document. I confirm that I have read and understand the above information and agree to undergo the treatment of my own free will. I further confirm that I do not suffer from any of the above-described conditions and that all the information I provided is accurate. I have had the opportunity to consider the following information, ask questions and have had these answered satisfactorily by the treating clinician.
By signing below you agree to the following:
Cancellation Policy:

We respectfully ask that you provide us with a 24 hour notice of any schedule changes or cancellation requests. Please understand that when you cancel or miss your appointment without providing a 24 hour notice we are often unable to fill that appointment time. This is an inconvenience to your therapist and also means our other clients miss the chance to receive services they need.
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Laser Hair Removal, IPL & Vein Therapy Intake Form

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Cancellation Policy: