Laser Treatment Consultation Form Name Date of Birth Gender Male Female Other Address Email Phone Number Emergency Contact 🔳Medical History Do you have any of the following medical conditions? Heart Disease High/Low Blood Pressure Diabetes Skin Disorders (e.g., eczema, psoriasis) Blood Disorders (e.g., anemia, clotting issues) Epilepsy/Seizures Allergies Other Are you currently taking any medications? Do you have any known allergies to medications or skincare products? Yes No If yes, please specify Have you had any previous surgeries? Yes No If yes, please specify Are you pregnant or breastfeeding? Yes No What is your natural skin tone? Very fair Fair Medium Olive Brown Dark Do you have a history of skin sensitivities or reactions? Yes No If yes, please describe Do you have any tattoos, permanent makeup, or recent piercings? Yes No Have you been exposed to tanning beds or direct sun within the past 4 weeks? Yes No Treatment Goals: What specific areas are you interested in treating? Face Underarms Bikini area Legs Arms Back Other What are your goals for laser treatment? Have you had previous laser treatments? Yes No If yes, please specify the type and date How would you rate your pain tolerance? Low Moderate High 🔳Consent and Acknowledgment:*I understand that laser treatments carry potential risks, including but not limited to redness, irritation, burns, or pigment changes. *I confirm that the information provided above is accurate and complete to the best of my knowledge. *I consent to the laser consultation and treatment process as explained to me by the provider. I Agree Client Signature Submit