Consultation Form: Brick, NJ: Get Lazed

Name*

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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

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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*

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Date*

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Consultation Form