SEE OUR

Last-Minute
Openings!

Name *

Age *

DOB *

Month

Day

Year

Occupation *

Phone # *

Address *

Which of the following best describes your skin type? *

I. Always burns, never tans

II. Always burns, sometimes tans

III. Sometimes burns, never tans

IV. Rarely burns, never tans

V. Brown, moderately pigmented skin

VI. Black skin

What is your ethnicity? *

When was the last time you were in the sun? *

Do you take any medications? If so, please describe. *

Do you have any allergies to medications? *

Do you have any allergies to latex? *

Do you have any allergies to Lidocaine? *

Have you ever had any laser treatments before? *

Please describe.

When was your last treatment?

What area?

Do you have any discoloration in the area to be treated from tanning/sun/self tanning? *

Please describe.

Do you form thick or raised scars from cuts or burns? *

Do you have any hyperpigmentation (darkening of the skin)? *

Do you have any hypopigmentation (lightening of the skin)? *

For female patients: Are you pregnant, trying to become pregnant, or breastfeeding?