SARAH LASER CENTER & MEDSPA

Skin | Laser

New Client Questionnaire & Medical History Form

In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential. Please read the content below then scroll to the bottom of the form to sign.

Date: April 25, 2024

Please select who will be receiving consult/treatment...

Adult Minor

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First Client's Name

First Name*

Last Name*

Phone*

First Client's Date of Birth*

First Client's Information

Age *

Occupation *

How did you hear about us?*

Other

SKIN HEALTH AND CONDITION

HOW WOULD YOU DESCRIBE YOUR SKIN? *

Oily

Sensitive

Dry

Normal

Combination

YOUR SKINCARE ROUINE *

Moisturizers

Masks

Peelings

Cleansers

Eye Products

SPFs

Toners

Serums

Scrubs

None

Other

PLEASE CHECK ALL THAT APPLIES *

I only use my favorite skincare brand

I'm constantly trying new things

I have used Rein A or Tretinoin in the last week

I have taken Accutane within the last 6 months

YOUR TREATMENT HISTORY *

RF Facial

Ultrasound Facial

IPL Photofacial

Laser Hair Removal

Chemical Peel

Dermaplaning

Microneedling

Microderambrasion

LED Therapy

Body Slimming / Cellulite treatments

Botox

Fillers

None

Other

YOUR AREA OF CONCERNS *

Breakouts / Acne

Rosacea

Sun Spots / Brown Spots

Wrinkles / Fine lines

Dull / Saggy skin

Blackheads / Whiteheads

Broken Capillaries

Uneven - skin / tone

Flaky skin

Under Eye Dark Circles

Cracks lips

Excessive Oil / Shine

Redness / Ruddiness

Sun Damage

Dehydrated

Under Eye Puffiness

Facial Folds - around mouth / nose

Unwanted hair

Neck Laxity

Cellulite

Pores (Nose)

None

Other

HAVE YOU EVER HAD AN ALLERGIC REACTION TO ANY OF THE FOLLOWING? *

Cosmetics

Sunscreens

Fragrance

Medicine

Iodine

Shellfish

Food

Pollen

Latex

Animals

AHAs

Drugs

No allergies

Other

PRODUCTS OR TREATMENTS OF INTERESTS TO YOU (please check all that apply)

Skin Care Advice

Skin Care Products

Lightening Cream

Facial / Peels

Laser Hair Removal

Laser Treatments

Microdermabrasion

Microneedling

Carbon Laser Peel

Chemical Peel

Dermaplane

LED Therapy

Body Slimming / Cellulite treatments

Radio Frequency / Ultrasound

Botox

Fillers

Other

Have you used Retin-A, Renova, Differin, or Tazorac in the past two (2) weeks?*

Yes

Have you used glycolic acid/AHA home care products in the past four (4) weeks?*

Yes

HAVE YOU HAD ANY OF THE BELOW SKIN TREATMENTS ON THE FACE IN THE LAST FOUR (4) WEEKS?

Chemical Peels

Laser Resurfacing

IPL Photofacial

Microdermabrasion

Botox/Filler

Laser Hair Removal

Microneedling

Dermaplaning

MEDICAL HISTORY PART I

Are you currently under the care of a physician?*

Yes

If yes, for what:

Are you currently under the care of a dermatologist?*

Yes

If yes, for what:

DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS? (please check all that apply) *

Active Acne

Allergies

Asthma

Arthritis / Gout

Blood clotting abnormalities

Cancer / Skin Cancer

Diabetes

Hepatitis

HIV/AIDS

PCOS

Rosacea

Seizure / Epilepsy

Keloid Scarring

Psoriasis / Eczema (on the treatment site)

Hormone imbalance

Thyroid Disease

Skin Marks/ Moles/ Freckles

Vitiligo

Pacemaker / Metal Implants

Lupus Erythematous

Nerve Problems

Lesions/ Sores/ Open wounds

Severe Histamine Reactions

N/A

Other

Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?*

Yes

Do you have any other health problems or medical conditions?

HAVE YOU EVER HAD AN ALLERGIC REACTION TO ANY OF THE FOLLOWING? (Please check all that apply and describe the reaction you experienced) *

Food

Latex

Aspirin

Lidocaine

Hydrocortisone

Hydroquinone or skin bleaching agents

Other

N/A

Other

Describe the reaction you experienced for all checked

MEDICAL HISTORY PART II

Have you ever used Accutane in the past six (6) months?*

Yes

If yes, when?

Have you used Antibiotics in the past four (4) weeks?*

Yes

If yes, when?

Have you had any recent exposure to sun/artificial tanning or used tanning spray/cream on the treatment area in the last two (2) weeks?*

Yes

Have you ever had laser hair removal? *

Yes

HAVE YOU USED ANY OF THE FOLLOWING REMOVAL METHODS IN THE PAST FOUR (4) WEEKS?

Shaving

Waxing

Electrolysis

Plucking

Tweezing

Stringing

Depilatories

Hair Bleaching

Do you form thick or raised scars from cuts or burns? *

Yes

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of marks) after physical trauma?*

Yes

If yes, please describe:

Do you have a history of bleeding coagulopathies or use of anticoagulopathies?*

Yes

Have you had skin cancer or precancerous lesions?*

Yes

If yes, please describe:

Do you have any active skin disease or infection in the area to be treated?*

Yes

If yes, please describe:

Are you undertaking a course of treatment that may make your skin photosensitive?*

Yes

If yes, please describe:

Are you allergic to latex, lidocaine, or any lotions?*

Yes

If yes, please describe:

Do you have any surgery on the treatment area?*

Yes

If yes, please describe:

Are you on any mood altering or anti-depression medication? (Please list):

What oral medications are you presently taking? Birth control pills/ Hormones/ Others (Please list):

List all other medications you have taken during last four (4) weeks (if none, please notated "NONE")

Females Only

Are you pregnant or trying to get pregnant?*

Yes

N/A

Are you breastfeeding?*

Yes

N/A

Any menopause problems?*

Yes

N/A

During any past pregnancy, did you develop hyperpigmentation or masking?*

Yes

N/A

Are you undergoing any hormone replacement therapy?*

Yes

N/A

Did you have a plastic surgery done (face or body)?*

Yes

N/A

If yes, please provide details:

Acknowledgement:

I certify that the preceding medical, personal 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 procedure.

First Client's Signature*

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Accept Signature Clear

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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

A signed copy of this waiver will be sent to the email address you provide.

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*

Relationship*

Phone*

Parent or Guardian's Date of Birth*

Parent or Guardian's Information

Age *

Occupation *

How did you hear about us?*

Other

SKIN HEALTH AND CONDITION

HOW WOULD YOU DESCRIBE YOUR SKIN? *

Oily

Sensitive

Dry

Normal

Combination

YOUR SKINCARE ROUINE *

Moisturizers

Masks

Peelings

Cleansers

Eye Products

SPFs

Toners

Serums

Scrubs

None

Other

PLEASE CHECK ALL THAT APPLIES *

I only use my favorite skincare brand

I'm constantly trying new things

I have used Rein A or Tretinoin in the last week

I have taken Accutane within the last 6 months

YOUR TREATMENT HISTORY *

RF Facial

Ultrasound Facial

IPL Photofacial

Laser Hair Removal

Chemical Peel

Dermaplaning

Microneedling

Microderambrasion

LED Therapy

Body Slimming / Cellulite treatments

Botox

Fillers

None

Other

YOUR AREA OF CONCERNS *

Breakouts / Acne

Rosacea

Sun Spots / Brown Spots

Wrinkles / Fine lines

Dull / Saggy skin

Blackheads / Whiteheads

Broken Capillaries

Uneven - skin / tone

Flaky skin

Under Eye Dark Circles

Cracks lips

Excessive Oil / Shine

Redness / Ruddiness

Sun Damage

Dehydrated

Under Eye Puffiness

Facial Folds - around mouth / nose

Unwanted hair

Neck Laxity

Cellulite

Pores (Nose)

None

Other

HAVE YOU EVER HAD AN ALLERGIC REACTION TO ANY OF THE FOLLOWING? *

Cosmetics

Sunscreens

Fragrance

Medicine

Iodine

Shellfish

Food

Pollen

Latex

Animals

AHAs

Drugs

No allergies

Other

PRODUCTS OR TREATMENTS OF INTERESTS TO YOU (please check all that apply)

Skin Care Advice

Skin Care Products

Lightening Cream

Facial / Peels

Laser Hair Removal

Laser Treatments

Microdermabrasion

Microneedling

Carbon Laser Peel

Chemical Peel

Dermaplane

LED Therapy

Body Slimming / Cellulite treatments

Radio Frequency / Ultrasound

Botox

Fillers

Other

Have you used Retin-A, Renova, Differin, or Tazorac in the past two (2) weeks?*

Yes

Have you used glycolic acid/AHA home care products in the past four (4) weeks?*

Yes

HAVE YOU HAD ANY OF THE BELOW SKIN TREATMENTS ON THE FACE IN THE LAST FOUR (4) WEEKS?

Chemical Peels

Laser Resurfacing

IPL Photofacial

Microdermabrasion

Botox/Filler

Laser Hair Removal

Microneedling

Dermaplaning

MEDICAL HISTORY PART I

Are you currently under the care of a physician?*

Yes

If yes, for what:

Are you currently under the care of a dermatologist?*

Yes

If yes, for what:

DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS? (please check all that apply) *

Active Acne

Allergies

Asthma

Arthritis / Gout

Blood clotting abnormalities

Cancer / Skin Cancer

Diabetes

Hepatitis

HIV/AIDS

PCOS

Rosacea

Seizure / Epilepsy

Keloid Scarring

Psoriasis / Eczema (on the treatment site)

Hormone imbalance

Thyroid Disease

Skin Marks/ Moles/ Freckles

Vitiligo

Pacemaker / Metal Implants

Lupus Erythematous

Nerve Problems

Lesions/ Sores/ Open wounds

Severe Histamine Reactions

N/A

Other

Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?*

Yes

Do you have any other health problems or medical conditions?

HAVE YOU EVER HAD AN ALLERGIC REACTION TO ANY OF THE FOLLOWING? (Please check all that apply and describe the reaction you experienced) *

Food

Latex

Aspirin

Lidocaine

Hydrocortisone

Hydroquinone or skin bleaching agents

Other

N/A

Other

Describe the reaction you experienced for all checked

MEDICAL HISTORY PART II

Have you ever used Accutane in the past six (6) months?*

Yes

If yes, when?

Have you used Antibiotics in the past four (4) weeks?*

Yes

If yes, when?

Have you had any recent exposure to sun/artificial tanning or used tanning spray/cream on the treatment area in the last two (2) weeks?*

Yes

Have you ever had laser hair removal? *

Yes

HAVE YOU USED ANY OF THE FOLLOWING REMOVAL METHODS IN THE PAST FOUR (4) WEEKS?

Shaving

Waxing

Electrolysis

Plucking

Tweezing

Stringing

Depilatories

Hair Bleaching

Do you form thick or raised scars from cuts or burns? *

Yes

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of marks) after physical trauma?*

Yes

If yes, please describe:

Do you have a history of bleeding coagulopathies or use of anticoagulopathies?*

Yes

Have you had skin cancer or precancerous lesions?*

Yes

If yes, please describe:

Do you have any active skin disease or infection in the area to be treated?*

Yes

If yes, please describe:

Are you undertaking a course of treatment that may make your skin photosensitive?*

Yes

If yes, please describe:

Are you allergic to latex, lidocaine, or any lotions?*

Yes

If yes, please describe:

Do you have any surgery on the treatment area?*

Yes

If yes, please describe:

Are you on any mood altering or anti-depression medication? (Please list):

What oral medications are you presently taking? Birth control pills/ Hormones/ Others (Please list):

List all other medications you have taken during last four (4) weeks (if none, please notated "NONE")

Females Only

Are you pregnant or trying to get pregnant?*

Yes

N/A

Are you breastfeeding?*

Yes

N/A

Any menopause problems?*

Yes

N/A

During any past pregnancy, did you develop hyperpigmentation or masking?*

Yes

N/A

Are you undergoing any hormone replacement therapy?*

Yes

N/A

Did you have a plastic surgery done (face or body)?*

Yes

N/A

If yes, please provide details:

Acknowledgement:

Parent or Guardian's Signature*

Type Signature

Draw Signature

Change Font

Accept Signature Clear

Click to Sign

Edit 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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