Client Information & Medical History "*" indicates required fields 1Personal Information2Medical History3Medications4History5Female Clients6Informed Consent for Hair Removal7Harmony Laser Policies Name* First Last Email* PhoneToday's Date MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY AgeSexMaleFemalePrefer Not to SayHome Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Emergency Contact Name Emergency Contact NumberWhich of the following best describes your skin type? (Select one) Always burns, rarely/never tans Sometimes burns, sometimes tans Sometimes burns, always tans Rarely burns, always tans Moderate pigmentation High pigmentation Are you currently under the care of a physician? Yes No If yes, for what? Are you currently under the care of a dermatologist? Yes No If yes, for what? Do you have a history of Erythema Ab Igne, a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared radiation? Yes No Do you have any of the following medical conditions? (Select all that apply) Cancer Diabetes HIV/AIDS Hepatitis Arthritis Epilepsy Skin Disease/Lesions Keloid Scarring Blood Clotting Abnormalities Thyroid Imbalance High Blood Pressure Herpes Hormone Imbalance Any Active Infections Do you have any other health problems or medical conditions not listed? Please list:Have you ever had an allergic reaction to any of the following? (Select all that apply) Food Latex Aspirin Lidocaine Hydrocortisone Hydroquinone or skin bleaching agents Other: What oral medications are you presently taking? Birth Control Pills Hormones Other oral medications? Are you on any mood altering or anti-depression medication? Yes No Have you ever used Accutane? Yes No If yes, when did you last use it? What topical medications or creams are you currently using? RetinA Others If Others, please list What herbal supplements do you use regularly? Have you ever had laser hair removal? Yes No Have you used any of the following hair removal methods in the past six weeks? Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories Have you had any recent tanning or sun exposure that changed the color of your skin? Yes No Have you recently used any self-tanning lotions or treatments? Yes No Do you form thick or raised scars from cuts or burns? Yes No Do you have hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)? Yes No If yes, please describe Are you pregnant or trying to become pregnant? Yes No Are you breastfeeding? Yes No Are you using contraception? Yes No Consent I certify that the preceding medical, personal and skin history statements are true and correct. 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.SignatureDate MM slash DD slash YYYY Treatment sites: mono-brow, lip, chin, neck, face, arms, fingers, chest, areola, underarms, back, buttocks, bikini, labia, scrotum, thighs, lower legs, feet, and toes. Combinations: Previous Hair Removal Methods(Shaving, Tweezing, Waxing, Depilatories, Electrolysis, Laser) The purpose of this procedure is to diminish or remove unwanted hair. The procedure requires more than one treatment and may produce permanent hair removal. The total number of treatments will vary between individuals. On occasion, there are patients that do not respond to treatments. The treated hair should exfoliate or push out in approximately 2-3 weeks. The following problems may occur with the hair removal system. There is a risk of scarring. Short-term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation (browning) and Hypo-pigmentation (lightening) have also been noted after treatment. These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Avoiding sun exposure before and after the treatment reduces the risk of color change. Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary. Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. Systemic reactions (which are more serious) may result from prescription medicines. I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation. Unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival at the office. Please be understanding if we cause you any inconvenience. Acknowledgment My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release Oksana Shushakova (individual) and Harmony Laser (facility) and its staff from all liabilities associated with the initiated procedure.Client/Guardian SignatureLaser Technician Signature Cancellation Policy: We kindly ask that you give us 24 hours notice if you must cancel or reschedule an appointment. If no-shows or no notice is given 24 hours prior to your appointment you will be charged a fee or a session will be removed from your package. Gratuity: We appreciate any gratuities given by our customer. Tipping envelopes will be located at the front desk or you may add gratuity onto your Venmo or Zelle. Refunds: Our treatments are non-refundable. There are no refunds or reimbursements made. Credit is available. In addition, packages are non-transferable. Antibiotics are not allowed to be digested 2 weeks prior to treatment. Client Agreement: By signing below, I certify that I have read, understand and agree with the policies of Harmony Laser. Client/Guardian Print Name Client/Guardian SignatureDate MM slash DD slash YYYY CAPTCHA
