LASER HAIR REMOVAL – CLIENT MEDICAL INTAKE & SCREENING FORM

Are you pregnant or breastfeeding? Are you pregnant or breastfeeding? Yes No

Do you have epilepsy or seizures (especially photosensitive)? Do you have epilepsy or seizures (especially photosensitive)? Yes No

Do you have a history of keloid or hypertrophic scarring? Do you have a history of keloid or hypertrophic scarring? Yes No

Do you have diabetes? Do you have diabetes? Yes No

Do you have any autoimmune conditions? (e.g., lupus, vitiligo) Do you have any autoimmune conditions? (e.g., lupus, vitiligo) Yes No

Have you had skin cancer or suspicious moles? Have you had skin cancer or suspicious moles? Yes No

Do you have any active skin conditions (eczema, psoriasis, acne)? Do you have any active skin conditions (eczema, psoriasis, acne)? Yes No

Do you have polycystic ovary syndrome (PCOS)? Do you have polycystic ovary syndrome (PCOS)? Yes No

Do you have a pacemaker or metal implants in the treatment area? Do you have a pacemaker or metal implants in the treatment area? Yes No

Are you currently taking Accutane (isotretinoin)? Are you currently taking Accutane (isotretinoin)? Yes No

Are you taking any antibiotics, antifungals, or acne meds? Are you taking any antibiotics, antifungals, or acne meds? Yes No

Are you taking any hormone therapy (e.g., birth control, HRT)? Are you taking any hormone therapy (e.g., birth control, HRT)? Yes No

Are you on blood thinners or anticoagulants? Are you on blood thinners or anticoagulants? Yes No

Are you taking any photosensitizing medications? Are you taking any photosensitizing medications? Yes No

Have you tanned or had sun exposure in the past 2 weeks? Have you tanned or had sun exposure in the past 2 weeks? Yes No

Have you used tanning beds or spray tans recently? Have you used tanning beds or spray tans recently? Yes No

Have you had a recent chemical peel, laser, or facial treatment? Have you had a recent chemical peel, laser, or facial treatment? Yes No

Do you have tattoos or permanent makeup in the treatment area? Do you have tattoos or permanent makeup in the treatment area? Yes No

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I have read and agree to the LASER HAIR REMOVAL – CLIENT MEDICAL INTAKE & SCREENING FORM HAVE ANSWERED ALL QUESTIONS HONESTLY AND UNDER STAND THAT IF THE CLIENT HAS ANSWERED YES TO ANY QUESTIONS WE WILL NOT BE PROVIDING SERVICES I have read and agree to the LASER HAIR REMOVAL – CLIENT MEDICAL INTAKE & SCREENING FORM HAVE ANSWERED ALL QUESTIONS HONESTLY AND UNDER STAND THAT IF THE CLIENT HAS ANSWERED YES TO ANY QUESTIONS WE WILL NOT BE PROVIDING SERVICES I have read and agree to the Disclaimer