Laser Hair Removal Intake Form

Name *

Phone # *

Cell Phone #

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country

Date of Birth *

Emergency Contact Name *

Contact Phone # *

Email Address *(To receive Appointments Reminders and Special Offers)

How did you hear about us?:

I consent to taking photographs for progress charting

Please initial to show your understanding to this statement *

Within the last year, have you been under a dermatologist or other physicals care? *YESNO

If Yes, When and for what are you being treated for?

Within last 60 days, have you had any type of esthetic work preformed? *YESNO

If Yes, When and what did you have done?

Are you pregnant or think you may be pregnant, or nursing? *YESNO

Do you smoke? *YESNO

Do you exercise regularly? *YESNO

Do you follow a restricted diet? *YESNO

Do you wear contacts? *YESNO

How many cups of water do you consume daily? *

Please list previous hair removal, methods and dates: *

Have you had any recent tanning, sun exposure or self-tanning lotion or treatments that changed the color of your skin? *YESNO

Do you form thick or raised scars from cuts or burns? *YESNO

Do you have Hyperpigmentation (darkening) or Hypopigmentation (lightening) of skin or marks after physical trauma? *YESNO

Please explain any checked conditions listed above and anything else you think your professional should be aware of: *

Please list any medications prescribed or vitamins (prescribed or over the counter) you are currently taking that you think your professional should be aware of *

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SKIN TYPE

To determine your skin type, please check the one box which best describes your reaction to sun exposure *Skin Type I Never tans, always burns (extremely fair skin, blonde/red hair)Skin Type II Occasionally tans, usually burns (fair skin, sandy to brown hair, green/brown eyes)Skin Type III Often Tans, sometimes burns during first exposure to sun (medium skin, brown hair)Skin Type IV Always tans, never burns (Olive skin, brown/black hair)Skin Type V Never burns (dark brown skin, black hair)Skin Type VI Never burns (black skin, black hair)

I understand there are no guarantees as to the results of this treatment. Please initial to show your understanding to this statement *

The purpose of this procedure is to dimmish or remove unwanted hair. The procedure requires more than one treatment and produce permanent hair reduction The total number of treatments will vary between individuals. On occasion there are patients that may not respond to treatments. The treated hair should exfoliate or push out in approximately 2-3 weeks. Compliance with the aftercare guidelines is important to prevent adverse effects. Please initial to show your understanding to this statement *

I understand that like liposuction surgery, non-invasive procedures do not rid the body of visceral fat. Please initial to show your understanding to this statement *

I have agreed to have Blvd spa preform esthetics and skin care services. Before my qualified professional can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below. I will notify my technician at anytime during or after this treatment of any
changes to my intake form or condition changes. If you checked off or answered yes to any of the questions above, Blvd Spa advises you to see your doctor regarding the risks or hazards of the proposed treatment before signing this consent form. If you choose not to see your doctor, you must acknowledge by signing below that Blvd Spa has asked you to visit your physician to obtain medical clearance before beginning treatments. You have elected not to do so and assume all risks for any injures arising from undertaking any treatments due to a known medical condition. Blvd spa still reserves the right to not begin any treatment under these conditions.

Waiver of Liability: Although every precaution will be made to ensure your safety and well-being before, during and after your procedure please be aware that your procedure is safe and there is no recovery time for most people. I understand there are risks associated with esthetic / skin care service procedures such as but not limited to: slight pink or redness to the skin, and will subside within a few hours of finishing the treatment, bruising, skin irritation, or worsening of breakouts, hyperpigmentation, hypopigmentation, and moles may occur and resolve themselves, but have the potential of being permanent. There is also the rare possibility of texture of scars, but can occur post-treatment. As part of this procedure, I will not attribute any liability to Professional or Blvd spa as a result of this procedure. I
understand that while every attempt to be made to provide you with a procedure that is exactly as you requested but every person reacts to products differently and you final results might differ from what you initially requested. I also agree to defend, indemnify and hold harmless Professional and Blvd spa from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against them as a result of my having this procedure performed, or my purchase of these Blvd spa products. As used in this agreement, the terms “Professional” and “Blvd spa” include all of their respective officers, directors, agents, employees, successors and assigns.

Care and Maintenance: I agree to follow the care and maintenance instructions provided by Blvd spa and/or Professional for the use and care of my skin, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that it is possible to feel slight irritation, tightness, and/or redness. These ae all common reactions which typically resolve themselves within 48-72 hours post treatment. As every clients experience is different, some clients may experience symptoms delayed. To maximize results, we recommend our at home maintenance products. The skin needs to be protected from excessive sun exposure. It is my responsibility to avoid waxing, lasers, aggressive exfoliation, and products containing any retinoids or
glycolic acids on the treated areas for at least two weeks after my treatment.

No Known Medical Conditions / Informed Consent: I have read and completed the Blvd spa Consent Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the professional’s or Blvd spa instructions or these warnings.

Disclaimer: I agree that I will not hold blvd spa and its employees liable for any injury or condition that arises from application of service despite completion of this form. This form is intended as an assessment tool only and serves as a guide for the application of service not for medical treatment or medical assessment. If I experience pain or discomfort during the session, I will immediately inform the professional so that the pressure may be adjusted. I understand that Professionals are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe or treat any physical illness, and that nothing in the course of the session given should be construed as such. Draping will be used during this session. No guarantee has been given by anyone as to the results that may be obtained by this treatment. The clients and all persons on the premises by invitation of the clients hereby hold blvd spa, its employees, independent contractors, the LLC or any individual connected in any way to blvd spa, Only the body area being worked on will be uncovered. Clients under the age of 18 must have a parent or legal guardian present to provide a signature for authorization for the session.

I have stated all conditions that I am aware of and this information I provided is true and accurate to the best of my knowledge. I agree to inform my professional immediately of any change in the conditions stated above on every visit moving forward. This consent form will stay on file and be used for this service and all future sessions. I acknowledge that this information is confidential and intended for review by blvd spa; that a medical referral may be requested of me; and that blvd spa is not liable for the management of any condition.

Client Signature (Parent/Guardian If Minor) *

Date *

Laser Hair Removal Intake Form

What areas are your primary concern(s) *

Have you used any of the following hair removal methods in the past six weeks?

Have you ever had an allergic reaction to any of the following?

PLEASE MARK ALL CURRENT AND PAST CONDITIONS *