LASER CONSULTATION FORM

LASER CONSULTATION FORM
Date/ Fecha

MonthDayYear
Date
Name / Nombre

NameLast Name
Telephone Number / Número de teléfono

Area codeTelephone Number
Email / Correo Electrónico
example@example.com
Area To Be Treated Today/ Areas Tratadas El Did De Hoy
PLEASE LIST ANY PAST OR PRESENT MEDICAL CONDITIONS/POR FAVOR MENCIONE CUALQUIER CONDICION MEDICA DEL PRESENTE O PASADO:
1. ALLERGIES: Please list any allergies you have/ ALERGIAS: Mencione alergias que tengas:
2. MEDICATIONS/MEDICACIONES
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?/ Tienes historial de alguna enfermedad autoinmune?

YESNO
4. Do you have a history of HSV 1 or HSV2?/ Tienes historial de HSV 1 o HSV 2?

YESNO
5. Do you have any tattoos?/ Tienes tatuajes?

YESNO
If yes please list where/ En que parte?
6. Are you pregnant?/ Estas embarazda?

YESNON/A
7. Do you have a history of keloids/hypertrophic scars?/ Tienes historial de keloides?

YESNO
8. Tanning: List the last date of tanning including direct sunlight,self-tanners, spray tans/ Por favor mencione las fechas de la ultima vez que te bronceaste, incluyendo el sol directo en la piel:
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.
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/ Entiendo que este procedimiento implica el uso de un láser y que el área tratada puede presentar un color turquesa, escamas o costras. Es posible que los resultados sean mínimos o no ayuden en absoluto. Realice que la respuesta de cada individuo es diferente; por lo tanto, podría requerir múltiples tratamientos para lograr los resultados deseados.
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/ Entiendo que la exposición al sol, las camas de bronceado, las lociones de bronceado sin sol y las cremas de bronceado deben evitarse durante al menos 4 semanas antes y durante el curso del tratamiento con láser o corro el riesgo de un posible cambio de pigmento o formación de ampollas. Se debe aplicar protector solar de SPF 30 o superior durante el curso de los tratamientos.
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/ Estoy de acuerdo en que la información enumerada ha sido revisada y presentada con mi claro entendimiento de lo que implica este procedimiento. Todas mis preguntas se han dirigido a mi satisfacción:

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CANCELLATION POLICY/POLIZA DE CANCELACION: If you need to cancel or reschedule your appointment, you are required to give us a 24-hour notice via call. Failure to cancel, reschedule or no-show up for the appointment will result in losing your deposit or you will lose a session from your package. Paid packages are ONLY good for up to 6 Months. / Si necesita cancelar o cambiar su cita, tiene que llamar 24 horas antes. Si no cancela, reprograma o no se presenta a la cita perdera su deposito o perdera una sesion de su paquete. Los paquetes pagados SOLO son válidos hasta por 6 meses.

In the event that a package, a series of treatments, and/or any of our services have begun, these services will be considered to have been rendered even though the full series may not have been completed. Should you wish to discontinue your treatment in the midst of a series, credit for the pro-rated share of unused treatments at the discounted package price may be extended, and this may be used to purchase other treatments or products offered by the Body Glow Spa Inc.

At Body Glow Spa Inc. we offer goods and services that are irrevocable. Therefore, we do not issue refunds for any of our products or our services, especially those that have been injected or used in your treatment. In consenting to be treated, it is important that you understand and accept this condition.

En el caso de que un paquete, una serie de tratamientos y / o cualquiera de nuestros servicios hayan comenzado, se considerará que estos servicios se prestaron aunque la serie completa no se haya completado. Si desea interrumpir su tratamiento en medio de una serie, se puede extender el crédito por la parte prorrateada de los tratamientos no utilizados al precio del paquete con descuento, y esto se puede usar para comprar otros tratamientos o productos ofrecidos por Body Glow Spa Inc.

En Body Glow Spa Inc. ofrecemos bienes y servicios que son irrevocables. Por lo tanto, no emitimos reembolsos por ninguno de nuestros productos o servicios, especialmente aquellos que han sido inyectados o utilizados en su tratamiento. Al dar su consentimiento para ser tratado, es importante que comprenda y acepte esta condición.
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