Laser Consent Form Page 2
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4HOW DID YOU HEAR ABOUT US?
WALKED PAST
LOCAL PAPER
INTERNET
FRIEND
OTHER: _____________________________________________________________
HAVE YOU HAD ANY SORT OF FACE PEEL IN THE LAST WEEK: Y/N
HAVE YOU HAD A MICRODERMABRASION IN THE LAST WEEK: Y/N
HAVE YOU HAD ANY LASER HAIR REMOVAL BEFORE:
AREA TO BE TREATED:
CURRENT METHOD OF HAIR REMOVAL? (Please circle)
Epilation
Shaving
Depilatories
Tweezing
Waxing
Electrolysis
Are you being treated for any medical conditions?
Y/N
If so, please specify_______________________________________________________
Do you have any skin allergies?
Y/N
If so, please specify_______________________________________________________
Are you on any of the following medications? (please circle)
Retin A (last 6 months)
Roacutane
Anti-coagulants
Anti psychotics
Photosensitive drugs
Steroids
Antibiotics
Aldactone/Androcur
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