Laser Treatment Consolation Form

Name *

Date *

Age *

Sex *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Home *

Work *

Cell *

Email Address *

Birthdate *

Emergency Contact Name and Phone Number *

How did you hear about us? *

Area(s) to be treated today *

Please list past or present medical conditions, illnesses, or allergies *

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) - Please list all medications, dosages, and date last taken: *

Do you have a history of any autoimmune disease? (i.e. Diabetes, Lupus, Rheumatoid Arthritis, Celiac) If so, please list

Do you have any tattoos? If so, please list location(s)

Are you or could you be pregnant? *YesNoN/A

Do you have a history of keloids/hypertrophic scars? *YesNo

Tanning history (direct sun, self-tanners, spray tans) – Please list and include last date of use:

Previous Laser Treatment(s) - If known, please specify date, number of treatments, frequency, response to treatment, device used:

Frequency and last use of above

Have you ever had a cosmetic peel or any other cosmetic procedure? If so, please list and include date of last treatment: *

Do you have a history of skin cancer or mole removal? *YesNo

Do you suntan? *YesNo

Do you use sunscreen? *YesNo

Do you smoke? *YesNo

Please list the brand of products you are currently using, if applicable:

Cleanser

Toner

Moisturizer

Eye Cream

Mask or Scrub

Sunscreen

Other

Have you ever used skin lightener or Retin-A? *YesNo

If yes, please list date of last usage

I agree that the all of information listed above will be reviewed and presented with my clear understanding of what this procedure involves. All of my questions will be addressed.

Signature *

Date *

Skin Typing Evaluation and Patient Evaluation Form

This information will help your esthetician to better evaluate your skin type so that your laser treatment will be more effective. Skin type is determined genetically and includes the color of your eyes, hair, etc. The way your skin responds to sun exposure is another way of correctly assessing your skin type. Recent tanning, whether by sun or an artificial tanning booth, even tanning creams, can have a major impact on your skin.

Genetic Disposition

(pick the description that best fits you):

Total score for genetic disposition (add all picked numbers): *

Reaction to Sun Exposure

(pick the reaction that best fits you):

What happens when you stay in the sun for a prolonged time? *0 - Painful redness, blistering, peeling1 - Blistering, followed by peeling2 - Burn sometimes, followed by peeling3 - Rarely burn4 - Never burn

Total score for reaction to sun exposure (add all picked numbers): *

Tanning Habits

(pick the habit that most applies to you):

When did you last expose your body to sun or tanning booth or tanning cream(s)? *0 - More than 3 months ago1 - 2/3 months ago2 - 1/2 months ago3 - Less than one month ago4 - Less than 2 weeks ago

Total score for tanning habits (add all picked numbers): *

you will be asked to add up these scores to get your total score and skin type.

Score for genetic disposition *

Score for reaction to sun exposure *

Score for tanning habits *

Total skin type score *

Skin Type Score	Fitzpatrick Skin Type
0-7	I
8-16	II
17-25	III
26-30	IV
Over 30	V-VI

Signature *

Date *

Laser Hair Removal Policy and Guideline Consent

I , *

, am aware that there is a specific guideline for laser hair
removal at Columbia Laser & Aesthetics that I will need to follow as listed below to obtain permanent
hair reduction.

Please thoroughly read and initial beside each statement:

I understand that my esthetician recommends a minimum of 9 laser hair removal treatments per area for all patients (regardless of any previous treatments at another facility) for best results. I understand that laser treatments are sold in packages of 3.

Please initial to show your understanding to this statement *

I understand that only after I have paid for and received all 9 treatments per area at Columbia Laser & AestheQcs am I eligible to receive a maximum of 3 complimentary follow-up appointments.

Please initial to show your understanding to this statement *

I understand that to see optimum results I will need to stay on a consistent schedule as advised by my esthetician (typically 4 weeks for smaller body parts, or 8 weeks for larger body parts) I am aware that if I do not stay on the schedule my esthetician recommends, I will not see results.

Please initial to show your understanding to this statement *

I understand that I am not to have any prolonged exposure to the sun or use any form of tanning (including self-tanners, spray tans, and tanning beds) 2 weeks before and/or 2 weeks after each of my scheduled appointment dates. I am aware that failure to avoid sun or tanning can result in adverse reactions such as hyper/hypopigmentation and/or burning of the exposed area(s).

Please initial to show your understanding to this statement *

I understand that I will not be able to have laser hair removal treatments if I have been on an antibiotic or have been taking any medications with a photo/sun sensitivity within the past 10 days (you will need to be scheduled for 10 days after the last day of taking such medications).

*Please note, if you have any questions you may ask your esthetician during your scheduled appointment time.

Signature *

Date *

Laser Treatment Consent Form

Please read and initial after each paragraph:

I am 18 years of age or older, or I am accompanied by a parent or legal guardian who will consent for me to have this treatment.

Please initial to show your understanding to this statement *

I acknowledge that the laser is a device that produces an intense but gentle burst of light. With this light, there is a minimal amount of risk. These risks (listed below) are typically associated with prolonged exposure to sunlight or use of a prohibited medication.

Please initial to show your understanding to this statement *

I understand that the following are possible risks and complications of this procedure including but not limited to:

Purpura (red-purple discoloration, bruising)
Itching (hive-like response which lasts 2-3 hours to 2-3 days)
Herpes simplex virus acQvaQon (only if you are already a carrier)
Burns, blisters, scabbing, crusting, skin color and /or textural changes
Hyperpigmentation (darkening of the skin; transient or long term)
Hypopigmentation (lightening of the skin; transient, long term or possibly permanent)
Scarring (rare, possibly permanent)

Please initial to show your understanding to this statement *

I understand that my eyes will be covered with laser-specific safety eyewear or an opaque material to protect them from the intense light. My eyes will be closed and I will not aempt to remove the eye protection during treatment.

Please initial to show your understanding to this statement *

I understand that complete clearing of my spider veins, brown spots, or redness may not be possible and will depend upon the type, age and color of the trouble spot. multiple treatments may be needed for the best results.

Please initial to show your understanding to this statement *

I understand that other methods of treating this condition will be discussed with me if I request, such that I may assess the risks and benefits of these alternative treatment methods.

Please initial to show your understanding to this statement *

I understand that anesthesia is usually not necessary. My provider or I may elect to use a form of topical anesthesia to reduce any discomfort during the procedure. A cryogen spray skin cooling device may be used during the procedure to decrease discomfort and protect the skin. All anesthesia options and risks will be discussed with me in advance if I choose to use.

Please initial to show your understanding to this statement *

I understand that immediately following the laser treatment redness, swelling, discomfort, whelping, bruising, and discoloration may develop at the treatment site. I understand that any discoloration may last 7-14 days and swelling should resolve within several days. Discomfort may be
treated with the application of cool compresses or topical soothing agents.

Please initial to show your understanding to this statement *

I understand I will be given complete instructions regarding after-care of the treated area. It is important to follow aftercare instructions carefully to minimize the chance of incomplete healing, skin textural changes or scarring. This includes, but is not limited to, avoiding sun exposure and tanning.

Please initial to show your understanding to this statement *

I have answered all questions about medical history and medications honestly and completely.

Please initial to show your understanding to this statement *

I am not pregnant (female patients).

Please initial to show your understanding to this statement *

I understand I will be given the opportunity to ask questions about the procedure and the procedure will be discussed in detail with me.

Please initial to show your understanding to this statement *

I recognize that the practice of medicine is not an exact science and acknowledge that no guarantees have been made to me concerning the results of such procedures.

Please initial to show your understanding to this statement *

I have read and understood all information presented to me before signing this consent form.

Signature *

Date *

Laser Treatment Consolation Form

Previous hair removal history, if applicable:

Please pick any of the following skin concerns you may have: