"Laser Hair Removal Assessment Form - Advanced Skincare Center"

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Download "Laser Hair Removal Assessment Form - Advanced Skincare Center"

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Leslie C. Gray, MD
9900 Medlock Bridge Rd.
Renee Cooper, RN, Laser Nurse
Johns Creek, GA 30097
Kim Higdem, Licensed Aesthetician
770.497.0699
Melissa Tyler, Licensed Aesthetician
www.dermatology-atlanta.com
A Division of Dermatology Center of Atlanta
LASER HAIR REMOVAL ASSESSMENT FORM
Patient: ___________________________________________
Date of Birth: __________________________ Acct #: ______________
Address: __________________________________________
City: ______________________
State: _________ Zip: __________
Home Phone: ___________________________
Work Phone: ___________________________ Cell Phone: _____________________
What area(s) do you wish to have treated?______________________________________________________________________________
Are you currently under the care of another physician:
No
Yes, please explain: _________________________________________
Please list any medication taken recently, especially Accutane (isoretinoin), photosensitizing drugs, St. John’s Wort, or gold salt injections:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Please list any allergies, especially to anesthetics: _______________________________________________________________________
Do you use glycolic products, exfoliating products, or Retin-A:
No
Yes, please explain __________________________________
Are you pregnant:
No
Yes
Have you had herpes or cold sores in the treatment area:
No
Yes
Do you have any unusual scars:
No
Yes, please explain ________________________________________________
Do you currently have or have you had:
Increase in amount of hair
No
Yes
Relative with unwanted hair
No
Yes
Dental filings, metal pins
No
Yes
Menopausal symptoms
No
Yes
Tattoos, permanent makeup
No
Yes
Do you have a tan
No
Yes
Photosensitive disorder (lupus, sun rash, vitiligo, porphyria, scleroderma)
No
Yes
Recent exposure to sun or tanning booth
No
Yes, when ______________
Previous laser, plucking, waxing, or electrolysis treatments
No
Yes, when ______________
Irregular periods
No
Yes
Hysterectomy
No
Yes
Hepatitis
No
Yes
Hives
No
Yes
Pacemaker
No
Yes
Diabetes
No
Yes
Keloid scarring
No
Yes
HIV/AIDS
No
Yes
Herpes
No
Yes
Cold sores
No
Yes
High stress
No
Yes
Hypertension
No
Yes
Heart problems
No
Yes
Laser resurfacing
No
Yes
Select the one description that would describe you if you were exposed to strong sun with no sun block:
I.
Always burn, never tan
II.
Always burn, sometimes tan
III.
Sometimes burn, always tan
IV.
Rarely burn, always tan
V.
I have moderately pigmented skin
VI.
I have darkly pigmented skin
What is your ethnic ancestry: ______________________________________________________________________________________
I attest the above information to be true, knowing my technician relies on this for safe and effective treatment.
___________________________________________________
______________________________________________________
Patient’s Signature (or parent/guardian if a minor)
Date
___________________________________________________
______________________________________________________
Treating Clinician
Physician
©Copyright 2011 Dermatology Center of Atlanta. All Rights Reserved.
Leslie C. Gray, MD
9900 Medlock Bridge Rd.
Renee Cooper, RN, Laser Nurse
Johns Creek, GA 30097
Kim Higdem, Licensed Aesthetician
770.497.0699
Melissa Tyler, Licensed Aesthetician
www.dermatology-atlanta.com
A Division of Dermatology Center of Atlanta
LASER HAIR REMOVAL ASSESSMENT FORM
Patient: ___________________________________________
Date of Birth: __________________________ Acct #: ______________
Address: __________________________________________
City: ______________________
State: _________ Zip: __________
Home Phone: ___________________________
Work Phone: ___________________________ Cell Phone: _____________________
What area(s) do you wish to have treated?______________________________________________________________________________
Are you currently under the care of another physician:
No
Yes, please explain: _________________________________________
Please list any medication taken recently, especially Accutane (isoretinoin), photosensitizing drugs, St. John’s Wort, or gold salt injections:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Please list any allergies, especially to anesthetics: _______________________________________________________________________
Do you use glycolic products, exfoliating products, or Retin-A:
No
Yes, please explain __________________________________
Are you pregnant:
No
Yes
Have you had herpes or cold sores in the treatment area:
No
Yes
Do you have any unusual scars:
No
Yes, please explain ________________________________________________
Do you currently have or have you had:
Increase in amount of hair
No
Yes
Relative with unwanted hair
No
Yes
Dental filings, metal pins
No
Yes
Menopausal symptoms
No
Yes
Tattoos, permanent makeup
No
Yes
Do you have a tan
No
Yes
Photosensitive disorder (lupus, sun rash, vitiligo, porphyria, scleroderma)
No
Yes
Recent exposure to sun or tanning booth
No
Yes, when ______________
Previous laser, plucking, waxing, or electrolysis treatments
No
Yes, when ______________
Irregular periods
No
Yes
Hysterectomy
No
Yes
Hepatitis
No
Yes
Hives
No
Yes
Pacemaker
No
Yes
Diabetes
No
Yes
Keloid scarring
No
Yes
HIV/AIDS
No
Yes
Herpes
No
Yes
Cold sores
No
Yes
High stress
No
Yes
Hypertension
No
Yes
Heart problems
No
Yes
Laser resurfacing
No
Yes
Select the one description that would describe you if you were exposed to strong sun with no sun block:
I.
Always burn, never tan
II.
Always burn, sometimes tan
III.
Sometimes burn, always tan
IV.
Rarely burn, always tan
V.
I have moderately pigmented skin
VI.
I have darkly pigmented skin
What is your ethnic ancestry: ______________________________________________________________________________________
I attest the above information to be true, knowing my technician relies on this for safe and effective treatment.
___________________________________________________
______________________________________________________
Patient’s Signature (or parent/guardian if a minor)
Date
___________________________________________________
______________________________________________________
Treating Clinician
Physician
©Copyright 2011 Dermatology Center of Atlanta. All Rights Reserved.