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SARAH LASER 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: June 13, 2021

Please select who will be receiving consult/treatment...
AdultMinor
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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?*
No
Yes
Have you used glycolic acid/AHA home care products in the past four (4) weeks?*
No
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?*
No
Yes

If 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) *
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?*
No
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?*
No
Yes

If yes, when?
Have you used Antibiotics in the past four (4) weeks?*
No
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?*
No
Yes
Have you ever had laser hair removal? ​*
No
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? ​*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of marks) after physical trauma?*
No
Yes

If yes, please describe:
Do you have a history of bleeding coagulopathies or use of anticoagulopathies?*
No
Yes
Have you had skin cancer or precancerous lesions?*
No
Yes

If yes, please describe:
Do you have any active skin disease or infection in the area to be treated?*
No
Yes

If yes, please describe:
Are you undertaking a course of treatment that may make your skin photosensitive?*
No
Yes

If yes, please describe:
Are you allergic to latex, lidocaine, or any lotions?*
No
Yes

If yes, please describe:
Do you have any surgery on the treatment area?*
No
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?*
No
Yes
N/A
Are you breastfeeding?*
No
Yes
N/A
Any menopause problems?*
No
Yes
N/A
During any past pregnancy, did you develop hyperpigmentation or masking?*
No
Yes
N/A
Are you undergoing any hormone replacement therapy?*
No
Yes
N/A
Did you have a plastic surgery done (face or body)?*
No
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*
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
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's 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.
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?*
No
Yes
Have you used glycolic acid/AHA home care products in the past four (4) weeks?*
No
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?*
No
Yes

If 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) *
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?*
No
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?*
No
Yes

If yes, when?
Have you used Antibiotics in the past four (4) weeks?*
No
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?*
No
Yes
Have you ever had laser hair removal? ​*
No
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? ​*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of marks) after physical trauma?*
No
Yes

If yes, please describe:
Do you have a history of bleeding coagulopathies or use of anticoagulopathies?*
No
Yes
Have you had skin cancer or precancerous lesions?*
No
Yes

If yes, please describe:
Do you have any active skin disease or infection in the area to be treated?*
No
Yes

If yes, please describe:
Are you undertaking a course of treatment that may make your skin photosensitive?*
No
Yes

If yes, please describe:
Are you allergic to latex, lidocaine, or any lotions?*
No
Yes

If yes, please describe:
Do you have any surgery on the treatment area?*
No
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?*
No
Yes
N/A
Are you breastfeeding?*
No
Yes
N/A
Any menopause problems?*
No
Yes
N/A
During any past pregnancy, did you develop hyperpigmentation or masking?*
No
Yes
N/A
Are you undergoing any hormone replacement therapy?*
No
Yes
N/A
Did you have a plastic surgery done (face or body)?*
No
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. 

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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