Patient Medical History - Laser Treatments

Name*

First

Last

Date*

Address*

Street Address

Address Line 2

City

Province

Postal Code

Main Phone Number*

Secondary Phone Number

Email*

Date of Birth*

How did you hear about Coral Spa?*

Describe the nature of your visit?*

What are your expectations?*

Please select any past or present health issues that you are experiencing or have experienced?*

Heart Condition
Keloids Scarring
Permanent Makeup/Tattoos
Cold Sores/Herpes
Pacemaker
LupusDiabetes Type 1 or 2
Epilepsy
Pregnant/Lactating

Are you currently pregnant?*

Yes
No

Are you breastfeeding?*

Yes
No

If yes, what is your Due Date?

Medications*

Blood Thinners
Antibiotics (past 2 weeks)
Accutane (past 6 months)
Sun-Sensitive Medications
Other

If you selected "yes" or "other" to any of the medications above, please indicate which medication & dosing

Do you have any allergies?

SKINCARE

Do you have a history of breakouts?*

Yes
No

If so, what is the frequency of your breakouts?

Frequent
Occasional
Rarely

Do you experience cystic breakouts?*

Yes
No

Do you have any scarring as a result from your acne?*

Yes
No

Skin Background

Have you had prolonged sun exposure (or tanning bed) in the past 3 days?*

Yes
No

If so, are you currently sunburned?

Yes
No

Do you use tanning beds?*

Yes
No

Are you using chemical tanning solutions?*

Yes
No

Do you use sunscreen on a regular base?*

Yes
No

Fitzpatrick I-VI

Select one (when exposed to the sun without protection for approximately 1 hour):

Skin Type*

Check one (when exposed to the sun without protection for approximately 1 hour):

Are you currently tanned?*

Yes
No

Have you waxed, used depilatories, bleaches or other chemical processes?*

Yes
No

How much water do you normally consume daily?*

Do you exercise?*

Yes
No

Do you smoke?*

Yes
No

Have you had microdermabrasion?*

Yes
No

Have you had any chemical peels?*

Yes
No

Have you had laser resurfacing?*

Yes
No

Do you have rosacea?*

Yes
No

Do you have wrinkle concerns?*

Yes
No

Do you have scarring concerns?*

Yes
No

Do you have sun damage concerns?*

Yes
No

Do you have pigmentation concerns?*

Yes
No

Do you have broken capillary concerns?*

Yes
No

Have you had Botox or Collagen injections in the past 6 months?*

Yes
No

If yes and less then 3 months, approximate dates?

Do you use:*

Topical Ointments
Retin-A
Glycolic
Lactic Acid
Hydroquinone
Other

Which skincare brand do you use?*

Check other services of interest:*

Laser Hair Removal
Laser Vein Removal
Non-ablative LaserFACIAL
Pigmented Lesions or Brown Spot Removal
Other

If you selected Laser Hair Removal, which area's?

If you selected Other, please specify

I understand that ANY type of sexual harassment/misconduct is absolutely forbidden. This is defined but not limited to the exposure of any body parts in the “bikini area” (unless I am doing a Brazilian/Bikini treatment), inappropriate touching, sexual innuendo’s, aggressive come-ons, comments about my providers physical appearance or comments which would make my provider fearful or uncomfortable. I also understand that failure to adhere to this policy will result in a lifelong ban from the facility.

I certify that the above medical history information is accurate and correct

Consent*

I have read everything above and understand it. I consent to to allow

Signature

Untitled

Patient Medical History – Laser Treatments

SKINCARE

Skin Background

Latest Products

Invisible Physical Defense SPF30

Clear Start FlashFoliant

Active Clearing Retinol Clearing Oil

Cosmetic Roll-CIT