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1011 Avenue of the Americas (Sixth Avenue), 2nd floor
New York, NY 10018

Phone: 646.870.6028
             646.870.6031
Email: spektrumlaserspa@gmail.com

Today's Date: April 24, 2025

I do understand that laser hair removal is not 100% permanent but a reduction of up to 90%.

I do understand the cancellation and rescheduling policy and agree to pay the appropriate fees if I do not cancel or reschedule within 24 hours of my appointment date and time.

I do understand that taxes, gratuities and shaving fees are not included in any service I purchase. It is common practice to tip 15-20% of the original service price.
Please feel free to extend a gratuity as a result of your space experience. Gratuities are accepted in the form of cash or credit card.

I do understand that if I fail to shave, my appointment will either be rescheduled or an additional shaving fee will apply (starting at $50). All sales are final and non-refundable.
However, exchanges can be made for any remaining credit toward other services we provide.

Thank You!

LATENESS & CANCELLATION POLICIES

I do understand our lateness, cancellation and rescheduling policy is as follows:

Please arrive at least 5 minutes before your scheduled time. Delayed arrival will limit the time of your experience, reducing the effectiveness of your treatment and the expectations of your visit. In consideration of other guests, service time will not be extended for delayed arrivals.

As we are by appointment only kindly give 24 hours advanced notice from your scheduled appointment time to cancel or reschedule.

Failure to provide such notice will result in a $50 fee for standard services or a $100 fee for full body services being charged to the card listed on your account. lf you do not agree to pay the fee your appointment will be rescheduled in six weeks from the date of your cancellation, which will result in losing one session.

A valid debit or credit card must be kept on file at all times. Unauthorized charges will not be made to your account and your billing information will not be shared.

I duly authorize Spektrum Laser Spa to perform the Soprano lce laser hair removal procedure and any other measures, which in their opinion, may be necessary.


I understand the Soprano Ice laser system is intended for hair removal and that clinical results may vary with different skin types, hair color and body location. I understand there is a possibility of rare side effects, such as scarring and permanent discoloration; as well as short-term effects, including redness, mild burning, blistering, temporary bruising and discoloration of the skin, such as hypo pigmentation (decrease in skin pigment) or hyper pigmentation (increase in skin pigment). These effects have been fully explained to me.

I understand that laser hair removal is not 100% permanent and is in fact a reduction of up to 90%. Moreover, no additional sessions will be added if the results are not as expected.

I understand that laser hair removal is not effective on blond and grey hair. Also, that on dark skin it will take more sessions to see the results. 

  I understand that I cannot change the treatment areas once I start the treatment. 

I understand that to achieve maximum results the protocol prescribed should be adhered to. The treatment schedule is designed to maximize the results during treatment of each hair cycle. If for any reason the schedule cannot be adhered to, I understand that the total percentage of hair loss could be affected. In addition, hair follicles that are dormant now may become active during or after my treatment program and additional treatments may be necessary. I also understand that I will have to pay for these additional treatments.

I understand that treatment by the Soprano Ice laser hair removal system involves a series of treatments and the fee structure has been fully explained to me.

I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

I confirm that I am not pregnant at this time and I will inform Spektrum Laser Spa if become pregnant in the future so I can stop all laser treatments immediately.

I confirm that I have not taken Accutane within the last 6 months and that I do not have a pacemaker or internal defibrillator.

I understand that taxes and gratuities are not included in any service I purchase. I do understand that gratuities are based on regular single session prices and not package or discounted prices.

I understand I need to stop tweezing, waxing, bleaching, using depilatories or any substance/medication that will damage the hair follicle. I understand I need to FULLY shave the hairs within 24 hours of my scheduled appointment time and failure to do so will result in my appointment being rescheduled or an additional shaving fee will apply.

I understand excessive sun exposure needs to be avoided two weeks before and two weeks after each treatment. For optimal results, I should attempt to maintain the same skin tone throughout the treatment process. Sun exposure, tanning bed exposure or the use of tanning creams could result in a less effective treatment and the technician choosing not to perform the treatment.

I understand that each appointment time is blocked off for individual treatments and in order to avoid a cancellation charge of $30 I will give 24 hours advance notice to cancel or reschedule so that the laser will be available for others.

I understand that all sales are final and non-refundable. However, exchanges may be made for any remaining credit toward other services we provide.

I understand that a $30 or $60 fee dependent on services rendered will be charged to the credit or debit card listed on my account if I fail to provide 24 hours advanced notice to cancel or reschedule.

I have read and understand this agreement and all my questions have been addressed and answered to my satisfaction. I consent to the terms of this agreement. Please note any coupon deals below:

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

MEDICATIONS:

What oral medications are you presently taking?
Birth control pills
Hormones
Others

Please list:

Are you on any mood altering or anti-depression medication?
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A
Others

Please list:

HISTORY:

Have you ever had laser hair removal?*
No
Yes
Have you used any of the following hair removal methods in the past four weeks? (only applicable to the areas being treated)
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes
Are you using contraception?*
No
Yes

I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

CLIENT INFORMATION & LASER/MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.

PERSONAL HISTORY


Occupation

How were you referred to us?
Which of the following best describes your skin type?*

MEDICAL HISTORY

Are you currently under the care of a physician?*
No
Yes

lf yes, for what:
Are you currently under the care of a dermatologist?*
No
Yes

If yes, for what:
Do you have any of the following medical conditions? (Please check all that apply)
Cancer
Diabetes
High Blood Pressure
Herpes
Arthritis
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease/Skin Lesions
Seizures
Hepatitis
Hormone Imbalance
Thyroid Imbalance
Blood Clotting Abnormalities
Any Active Infection

Do you have any other health problems or medical conditions? If so, please list:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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