5 Steps subbmission form STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Client Name Gender MaleFemale Phone Number E-mail Address: Theraphist DOB: Select Day01020304050607080910111213141516171819202122232425262728293031 Select Month010203040506070809101112 Select Year19701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Next STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Please specify the conditions that apply to you: AcneAllergiesAsthmaAutoimmune DisorderBurnsCancerDry PatchesDiabetesEpilepsySun DamageHormonal ImbalancesHeart ConditionHirsutism (excessive hair growth)Facial or other visible scarsGrafted SkinDepression / Mental HealthPsoriasisPregnancyNomaNerve DamageSteroidal or Hormone TherapyThyroid ImbalanceVitiligo or HyperpigmentationPort Wine StainKidney DiseaseHerpes (or Cold Sores)Polycystic Ovarian SyndromeShinglesLupusOther Are you currently being treated for any conditions not listed above? YesNo BackNext STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Are you currently taking any medication, including painkillers/antihistamines? YesNo Please select if you are currently taking any of the below: TetracyclineActrimHydrochlorlthiazide Are you taking any medication causing sensitivity when exposed to the sun? YesNo Are you currently or have you ever received radiation therapy? YesNo Please select if you have ever used or are currently using any of the below: Retin AAccutaneAlpha HydroxylGlycolic Acid Have you ever had a clinical peel? YesNo Have you had any laser or IPL treatments in the last 6 months? YesNo How would you best describe your skin. Please select: OilyOily to NormalNormalDryNormal to DryDrySensitive Do you have any implants, including dental implants? YesNo Do you have any tattoos or semi-permanent make-up? YesNo Have you ever been treated by an endocrinologist? YesNo Do you have any particular skin sensitivities? YesNo Have you had any large or small surgeries performed in the last 3 months? YesNo For women, when was the last day of your period? BackNext STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Please select the area you should like to have treated: Upper LipHandsShouldersEarsChinBackFeetUnderarmsNeckSides of FaceNipplesChestUpper ArmsLower ArmsUpper LegLower LegBikiniAbdomenButtocksBreastsFull BodyOther What hair removal methods have you used in the past? Please select: Waxing PluckingLaserIPLDepilatory CreamsBleachingShavingElectrolysisOther If other, please specify: Please indicate your ethnic background. Also, please indicate if your parents or grandparents are of a different race, so we can accurately ensure the right settings for your skin type: How often do you sunbathe? How does your skin response to the sun? Please select: Always BurnSometimes BurnNever BurnAlways TanNever TanSometimes Tan When did the hair growth that you wish to treat appear?PubertyMenopauseAdulthoodFrom MedicationFrom Pregnancy Please select your hair structure: LargeMediumSmall Please select your hair color: WhiteGreyBlondeBrownBlackRed BackNext STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Informed Consent Form I consent to and authorise Tamara's Health & Beauty Clinic/practitioner to perform Laser assisted hair removal on me. The laser is a device that produces an intense burst of light that fragments and removes the hair with selective destruction, without harming the surrounding tissue. To protect my eyes from the intense light, I will wear laser protective glasses. Device Versus tm Color Triple Wavelenghth Diode Laser used for Skin types I - III and skin types IV - VI. I have been informed that scarring, blistering, purpura, hyperpigmentation and hypopigmentation are possible risks and complications of this procedure. Usually if these occur they are temporary and will resolve within a few days/weeks. I understand that immediately following the Laser treatment the treated area will appear as a red discolouration with swelling and heat which may last up to 48 hours. The erythema (redness) may last up to 7 days. The area will feel like sunburn but this is expected post treatment. I am aware I will need to inform my practitioner if I am going to be, or have been in the sun/a sunbed or used any tanning products as this will contraindicate my treatment. Improper care of the treated area may increase chances of scarring or skin textural changes. This has been discussed with me in my patch test/consultation. For best results I have been informed multiple treatments will be necessary and changes in hormone levels at stages like pregnancy/menopause and medications can effect regrowth. I have read and understand all information presented to me before signing this consent, and my questions regarding the treatment have been answered to my satisfaction. (or person legally authorised to consent for me) Back
