LASER CONSULTATION FORM

LASER CONSULTATION FORM
Date

Month Day Year
Area To Be Treated Today
Name / Nombre

Name Last Name

Address / Dirección

Address 1
Address 2
City	State
Zip Code	País

Telephone Number / Número de teléfono

Zip Code Telephone Number
Email / Correo Electrónico
example@example.com
Age
Sex
PLEASE LIST ANY PAST OR PRESENT ILLNESSES/MEDICAL CONDITIONS:
1. ALLERGIES: Please list any allergies you have:
2. MEDICATIONS:
Please list any oral or topical medications you are taking. (Accutane, Antibiotics, Aspirin, Antiviral, Iron Supplements, cold medication, Coumadin, or anything that may cause photosensitivity including herbal supplements)
3. Do you have a history of autoimmune disease?

YES NO
4. Do you have a history of HSV 1 or HSV2?

YES NO
5. Do you have any tattoos?

YES NO
If yes please list where
6. Are you pregnant?

YES NO N/A
LMP
7. Do you have a history of keloids/hypertrophic scars?

YES NO
8. Tanning: List the last date of tanning including direct sunlight,self-tanners, spray tans:
9. Laser Treatment History: Please list any previous laser treatment, Include dates, number of treatments, frequency,tissue response, and please list device used if known:
10. Hair Removal : Please list any hair removal history if applicable.
11. Have you ever List any other types of treatment, frequency, and last use of modalities: had a cosmetic peel/cosmetic procedure?

YES NO
12. List any other types of treatment, frequency, and last use of modalities:
FOR STAFF ONLY / Recommendations: Discussion with provider

1. Treatment options (testing, brown or black hair responds best, number of treatments). 2. Client expectations: (understand need for multiple treatments, after care, possible side effects, ect.) 3. Physician consultation (If required in your state) before of aftertaste for a treatment recommendation. 4. Full treatment schedule process (waiting period in-between treatments, expected results. 5. Possible side effects (hyperpigmentation, hypopigmentation, purport, scarring, textural changes, burns, blistering, pain or discomfort and erythema) and length of time to expect healing if side effects occur. 6. Specifics of area to be treated. Test small area for tissue response BEFORE full treatment. 7. Importance of sun exposure avoidance and the use of a broad spectrum zinc oxide or titanium dioxide UVA/B sun block with SPF 30 or higher during the entire treatment program. 8. Sensation of the laser/DCD spray and the option for the topical anesthesia or other cooling methods. 9. Benefits of laser treatment (possible long-term hair removal) 10. Cost of treatment (payment schedule, cost of multiple treatments versus single payment per visit). 11. Eyewear protection and laser safety measures required for patient and provider. Patients may sense light while wearing proper eye protection. 12. Importance of post care instructions/procedures.
Photo taken today?

YES NO
COMMENTS:
I agree that the information listed has been reviewed and presented with my clear understanding of what this procedure involves. All of my questions have been addressed to my satisfaction:

Clear
Fecha

Mes Día Año
Fecha
Witness:

Clear
Fecha

Mes Día Año
Fecha
(Patient initial) *
(Dr/Tech’s initial). *
I understand that sun exposure, tanning beds, sunless tanning lotions, and tanning creamsare to be avoided for at least 4 weeks prior to during, and 4 weeks after the course of lasertreatment or I risk a possible pigment change or blistering. Sunscreen of SPF 30 or higher shouldbe applied during the course of treatments.
(Patient initial) *
(Dr/Tech’s initial). *
I understand this procedure involves the use of a laser and the treated area may turndarker in color, flake, or crust. It is a possibility the results will be minimal or not help at all. Irealize that each individual’s response is different; therefore it could require multiple treatmentsto achieve desired results.
(Patient initial) *
(Dr/Tech’s initial). *
I understand and agree that Dr. ________ may choose to take photos of my treatmentarea for the purpose of monitoring my progress
(Patient initial) *
(Dr/Tech’s initial). *
I also understand that once I’ve started my treatment program there are no refunds
(Patient initial) *
(Dr/Tech’s initial). *
I have received post treatment instructions.
(Patient initial) *
(Dr/Tech’s initial). *
Tech ________ or an employee of tech . ________ has explained the nature and purpose ofpigmented lesion removal, including any risks and possible complications, and it has beendiscussed the contents of this form with me. I have read and understand this consent form and Iagree to its terms and authorize treatment. I further understand that Tech ___ ________ cannot guarantee the results and I will not hold tech__________ or his/her employees responsible for myindividual results of this treatment that I have requested.
(Patient initial) *
(Dr/Tech’s initial). *
Print Patient Name

Name Last Name
Patient Signature:

Clear
Date

Mes Día Año
Date
Witness:

Clear
Date

Mes Día Año
Date
Should be Empty: