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Laser Skin Consultation Form

Please take a moment to fill out the form.

Birthday
Day
Month
Year
Are you currently under a doctor’s care?
Yes
No
Do you have any known medical conditions?
Yes
No
Are you pregnant or breastfeeding?
Yes
No
Do you have any heart conditions or pacemaker?
Yes
No
Do you have epilepsy or seizures?
Yes
No
Do you suffer from keloid or hypertrophic scarring?
Yes
No
Do you have any skin disorders (e.g., eczema, psoriasis, rosacea)?
Yes
No
Do you have melasma or a history of pigmentation issues?
Yes
No
Do you have a history of herpes simplex (cold sores)?
Yes
No
Do you have any active infections, open wounds or skin lesions?
Yes
No
Have you had a professional skin check in the last 6 months?
Yes
No
Are you currently on any medication (oral or topical)?
Yes
No
Are you on Roaccutane (Isotretinoin) or have used it in the last 6 months?
Yes
No
Do you have any allergies (especially to products, latex, or anaesthetics)?
Yes
No
Have you had cosmetic treatments in the past 4 weeks (peels, microneedling, injectables)?
Yes
No
Have you had laser treatments before?
Yes
No
1. What skin concerns would you like to address?
2. How would you describe your skin type?
3. Have you used any skincare products with retinoids, AHAs/BHAs, or vitamin C in the last 7 days?
4. Have you had recent sun exposure or are you planning sun exposure within 7 days of treatment?
Yes
No
5. Do you wear SPF daily?
Yes
No
6. Have you used fake tan in the past 2 weeks?
Yes
No
Treatment Consent Acknowledgement
Date
Day
Month
Year
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