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Consent Form /Medical History Permanentlyyou
APPROVAL FOR LASER TREATMENT
First & Last Name
Email
Address
City
Postal Zip Code
Province
Phone Number
Birthdate
Emergency Contact Name
Emergency Contact Number
Allergies & Sensitivity (Please List)
Skin Conditions (Select all that apply)
Acne
Rosacea
Acne Scars
Aging Skin
Back Acne
Chest Acne
Blacheads
Whiteheads
Blistering Sunburns
Burn
Cosmetic products reactions
Dark under eye circles
Dermatitis
Dry skin
Eczema
Elastosis (Sagging skin)
Seborrheas (excessive oiliness)
Sensitive Skin
Aloe Allergy
Skin Cancer
Skin Discoloration
Tattoos
Enlarged Pores
Freckles
Herpes Simplex (Cold Sores)
Hyperkeratinisation
Hyperpigmentation (age spots)
Hypopigmentation (white spots)
Keratosis pilaris (Skin bumps)
Lines/Wrinkles
Moles
Pseudo Folliculitis barbae (ingrown-hair)
Psoriasis
Salicylic/aspirin allergy
Scarring (Raised, depressed,flat)
Keloid Scarring
Cherry Hemangomias
Strech Marks
Sun Damage
Telangiectasia
Uneven texture
Vitiligo
Please list your top 3 Skincare concerns in order of priority
1
2
3
SUN EXPOSURE
How do you react to the Sun?
Always burn, never tan
Burn first, tan with difficulty
Burn first, tan with ease
Seldom burn, tan with ease
Never burn, always tan
Sun Exposure?
Ocasional
Occupational
recreational
Do you use tanning beds?
Yes
No
If, yes, How often?
Weekly
Monthly
Several times a week
A few times per year
Do you use self tanner?
Yes
No
Do you use sun protection?
Yes
No
When were you last exposed to the sun?
Less than a week
2 weeks
1 month
COSMETIC MEDICAL HISTORY
Are you under the care of a Dermatologist?
Yes
No
If Yes, reason for treatment?
Do you currently use, or are currently taking, this medications?
Retinol
Accutane
Birth control pills
Hormone replacement therapy
Anticoagulants
Aspirin
Analgesics
Antinflammatory
Antiepileptics
Antibiotics
Insulin
High blood pressure drugs
Other (details)
If Yes, When?
Have you had plastic surgery
Yes
No
If Yes, which Procedure
When
Have you had Cosmetics injections?
Yes
No
If Yes, what?
Body part?
When
have you had any of the following Cosmetics treatments (check all that apply)
Peels
Hair Removal
Photo facial
Laser resurfacing
Body/face contouring
Micro needling
Micro Blading
GENERAL MEDICAL HISTORY
Do you have or ever had Skin Cancer?
Yes
No
When
Where
Type:
Please list all current medications:
Please list all relevant surgeries and when
Please check all that apply
Anxiety Depression
Cancer
Constipation
Contact lenses
Chrons /IBS
Diabetes
Epilepsy
Pacemake
Arrhytmia /Disrrhytmia
Hearing aids
Heart disease
Hepatitis
HIV
Lupus
Arthritis
Asthma
Implants (metal, silicone)
Thyroid disorder
IUD
Menopause
Pregnant
Breastfeeding
LIFESTYLE
Have you had childrens?
Yes
No
How would you rate your stress level
High
Moderate
Low
On average how much sleep you get per night?
More than 8 hours
6-8 hours
Less than 6 hours
How would you rate your diet?
Healthy
Poor
Vegetarian/Vegan
Restricted
How would you rate your diet?
How much of the Following you have each day?
Coffee
Water
Alcohol
Cigarrettes
How often do you exercise?
Less than 2 days a week
3 days a week
More than 5 days a week
Please Check, I Agree
A complete and accurate medical history is important to ensure that it is safe for you to receive treatment and to determine the most beneficial treatment and products.
Treatment protocol is based solely on the information provided.
By pressing SUBMIT, you understand that the information you have provided above is to the best of your knowledge and will be kept confidential exclusively by Permanentlyyou.
Electronic Signature
By accepting this Consent, you agree to an Electronic signature on File
Signature
Submit
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