Consultation Form: Get Lazed

Name*
First Last
Age*
Sex*
Date*
Areas to be treated*
Past or present Illness/ Medical Conditions/ Allergies, please list*
Present Medications*

Accutane, Antibiotics, Aspirin, Iron supplements, Gold therapy, Cournadin, drugs which may cause photosensitivity this includes herbal supplements
Please list dosage of oral antibiotics/Accutane and date of last dose taken:*
Please list any topical medications you are using:*
Do you have a history of any autoimmune disease?*
Do you have a history of HSV1 or HSV2?*
Do you have any implants/ injectables/ permanent make-up? Ifso, please list:*
Do you have any tattoos? Please list locations:*
Are you pregnant?*
Do you have a history of keloids/hypertrophic scars?*
Tanning History (including direct sun, self tanners, spray tans) Please list and last date of use:*
Previous Laser Treatment: (specify date/ number of treatments/ frequency/ tissue response/ device used)*
Previous Hair Removal History*
select all that apply
Frequency/ last use of above modalities:*
Other type treatment
Untitled
Have you ever had a cosmetic peel/procedure? Please list*
I agree that the information listed above has been reviewed and presented with my clear understanding of what this procedure involves. All of my questions have been addressed to my satisfaction*
First Last
Date*
Phone*
Email
Fitzpatrick Skin Quiz Score (Link at top of the page)