Patient Consent Form For Laser Genesis Skin Therapy Treating Warts
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4Name______________________________________________ Birthdate_____/_____/_____ Sex M / F
Email ______________________________________________ Phone __________________________
Address ________________________________________ City__________________ Zip ___________
Emergency Contact ____________________________________ Number ________________________
Allergies_____________________________________________________________________________
How did you hear about Look Young Atlanta?________________________________________________
Please circle any past or current medical conditions:
Lupus / Auto-Immune Deficiency
Accutane Treatment
Diabetes
Pregnant
Keloid or Thick Scarring
Epilepsy
Bleeding Abnormalities
Herpes Simplex / Fever Blisters
Scars that turn white or brown
Dark Spots after Pregnancy
Psoriasis or Vitiligo
Leg Ulcer or Phlebitis
Blood Thinning
Rheumatoid Arthritis
Cystic Acne
HIV
Hepatitis
Waxing/Plucking in last 4 weeks
Hirsutism
Transplant Anti-rejection Drugs
Skin Cancer
Permanent Makeup
Surgical Implants
Metal Implants
Chemical Peels
Microdermabrasion
Laser Resurfacing or Facelift
Please list any past or current medical conditions that are not listed above:
Please list any medications or herbal supplements that you are currently taking, including topical
medications:
Please circle any procedures about which you would like to receive more information:
Weight Loss/More Energy
Hormone Replacement Therapy
Laser Hair Removal
Botox/Fillers
Sun Damage Removal
Wrinkle Removal
Decreasing Pore Size
Decreasing Acne Scarring
Laser Vein Removal
By my signature below, I certify that the above medical information is true and accurate.
931 monroe drive | suite 102-494 | atlanta, georgia 30308 | 404-239-3911
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