First name

Last name

Address

Phone

Email

Doctors Name and Address

Address

Emergency Contact Name and Number

Phone

Ethnic Origin

Occupation

Treatment Requested

Please Tick

Other Body Area(s)

Lifestyle and Medical History - Please choose in the box appropriate. If you do not understand or recognise the condition then please discuss with your laser/IPL Operator

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Allergies

Other

Units Alcohol

Are you currently taking any medication or any supplements? No/Yes (Please specify the condition and medications)

Currently using/used in the last 3 months any of the following? (Please tick)

Please Tick

Comments

Recovering from any major medical treatment or photodynamic therapy (PDT) within the last 6 months?

No/Yes (Please specify)

Has the area for treatment: Ever had any of the following?

Please Tick

Suffred from any skin disrder/disease? No/Yes

Had previous Laser or IPL treatment? No/Yes

Your Skin: What products do you use for your skin?

Please indicate how your skin responds to midday summer sun exposure with no sunscreen:

Please Tick

Skin type 1 Always burns, never tans

Skin type 2 Easily burnt, eventually gets a moderate tan

Skin type 3 Sometimes burns, quickly gets on average tan

Skin type 4 Rarely burns, quickly gets a deep tan

Skin type 5 Very rarely burns, constant tan

Skin type 6 Never burns, consistent tan

Do you currently have real or fake tan?

Please Tick

Fake

Real

Have you had any sun exposure or sun beds in the last four weeks?

Please Tick

Yes

No

What are your goals or expecations for the treatment?

Treatment assessment to completed by the Operator

Hair Removal Assessment (please select)

Hair Colour

Please Tick

Hair Texture

Please Tick

Coarse

Medium

Fine

Handpiece Selection

Please Tick

650

65 Advance

Nd YAG

Alexandrite

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