Laser Consent Form

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LASER CONSENT FORM
NAME: ________________________________________________________________________________
ADD: _________________________________________________________________________________
______________________________________________________________________________________
PHONE (H):___________________________________ (M):_____________________________________
EMAIL: _______________________________________________________________________________
OCCUPATION: ________________________________________________________________________
AGE:
ARE YOU PREGNANT OR TRYING TO CONCEIVE: Y/N
ETHNIC ORIGIN:_______________________________________________________________________
FITZPATRICK SKIN TYPE
DESCRIPTION
(PLEASE TICK)
Type 1 -Never tans, always burns
Fair Skin, Blonde Hair, Blue/Green Eyes
Type 2 - Occasionally Tans, usually Burns Fair Skin, Sandy-Light Brown Hair, Green or Brown Eyes
Type 3 - Often Tans, Sometimes Burns
Medium Skin, Brown Hair, Brown Eyes
Type 4 - Always Tans, Never Burns
Olive Skin, Brown/Black Hair, Brown/Black Eyes
Type 5 - Never Burns
Dark Skin, Black Hair, Black Eyes
Type 6 - Never Burns
Black Skin, Black Hair, & Black Eyes

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