To ensure we deliver the highest quality care and develop the most effective treatment plans for our clients, we require our clients to complete a new health history form on annual basis.

This comprehensive form is crafted to offer valuable insights into your overall health and lifestyle patterns. By answering the questions thoroughly, you enable us to understand better your unique health needs and the factors influencing your well-being.

Please note that the health history form is not intended to provide a medical diagnosis.

Instead, it helps us identify your current health strengths and any potential risk factors. This information is crucial in allowing us to tailor our care specifically to you, ensuring you receive the best possible support for your health journey.

Your Information

First Name *

Last Name *

Email *

Phone *

Address

Street Address *

City *

Country *

Postal code *

Apartment Number / Suite Number (if applicable)

Date of birth *

How did you hear about us? *

Word of mouth

Google

Social Media

Other

Lifestyle Questions

When were you last exposed to the sun (including tanning booths)? *

Occupation *

Do you or have you ever smoked? *

Current smoker

Former smoker

Non-smoker

If yes, how many packs per day?

If you are a former smoker, when did you quit smoking?

Do you drink alcohol? *

Yes

If yes, number of alcoholic drinks per week?

Do you have any permanent make-up or tattoos on the area to be treated?*

Yes

Skin type (when exposed to the sun without protection for one hour): *

Always burns, never tans

Sometimes burns/sometimes tans

Always burns, sometimes tans

Always tans

Describe your skin & your present skin care regime? What skin care product line are you currently using? *

Have you ever had an allergic reaction to a product applied to your skin? *

Yes

Treatment History

Date of last treatment

Expectaions

Health Background

Any Known Medical Conditions *

How would you describe your overall health? *

Excellent

Good

Fair

Poor

Please list all (medical or cosmetic) past surgeries and dates. *

Please list all of the medications you are currently taking and the condition it treats: *

Are you on any type of hormone therapy: *

Yes

Please list all allergies: *

Your Goals

What do you hope to accomplish during treatment? *

Do you have a specific skin condition you wish to correct? *

Are you interested in our hair restoration services? *

Yes

If YES: you are interested in our hair restoration services please ensure you complete our hair loss questionnaire.

When looking in the mirror, I am somewhat concerned, not concerned or very concerned about the appearance of my wrinkles. *

Not Concerned

Somewhat Concerned

Very Concerned

Photo/Video and Social Media Consent

At LMC, we take pride in transparency, education & innovation. As part of our commitment to these values, we may document certain procedures & treatments for educational, research, and informational purposes, always with your consent.

Our content may include photos & videos that showcase medical aesthetics treatments being performed or explained. These materials help inform our community, educate other professionals, & provide current & potential patients with accurate expectations about outcomes & recovery. They also raise awareness about the services we offer at LMC.

Privacy & Confidentiality

Your privacy is our priority. Unless you explicitly provide written consent, your name & facial identity will always remain confidential. We follow strict guidelines based on the Ontario Privacy Commissioner’s standards. No photo or video will be taken, used, or shared without your permission. You are under no obligation to consent, and you can withdraw your consent at any time by notifying us in writing.

Before & After Images
• These are common in cosmetic medicine and may appear on our website, social media, scientific presentations, or educational materials
• They serve to show the transformations our treatments can achieve and help others understand realistic outcomes
• Identifiable features will be hidden or blurred when shared publicly to preserve your anonymity

Educational Content (Storytelling Media)
• With consent, we may share consultation clips, treatment walkthroughs, and post-treatment updates on platforms like Instagram, TikTok, YouTube, Facebook, and more
• This real-time and visual approach helps patients better understand procedures and make more informed decisions about their care
• These videos are powerful tools for educating others about aesthetics and the LMC experience

Where We May Share Content
• LMC website(s): www.lasermedicalclinic.com
• Social platforms: Instagram, TikTok, Facebook, X (Twitter), YouTube, Snapchat, Vimeo

Your Rights
• You do not need to consent to media use in order to receive care or treatments at LMC
• You can opt out or revoke permission at any time
• We respect and prioritize your boundaries and comfort at every step

Important Notes:
• I understand these media materials are not part of my medical record.
• I understand that photos and videos may be deleted or reposted at any time.
• I acknowledge that shared media may be viewed, saved, or reshared by other accounts or individuals beyond LMC’s control.
• I understand that if I withdraw my consent in the future, LMC will remove my images/videos from their official platforms, but cannot guarantee full removal from the internet once shared.

I consent to the use of my treatment photos to create Before/After images that may be shared on the websites and platforms mentioned above (e.g., LMC website, Instagram, TikTok, RealSelf, etc.). Your face and name will not be shown unless you give explicit permission. *

YES

I consent to have my procedure(s) and/or clinic visits recorded for educational and social content to be posted on the platforms listed above. Your face and name will not be shown unless you give explicit permission. *

YES

If I answered YES to either section above, I request the following be concealed in any shared content:

My Face

Tattoos or birthmarks

Other identifiable features

Your Understanding

I understand the clinical results may vary depending on individual factors, including medical history, skin and hair type, patient compliance with pre/post treatment instructions, and individual response to the treatment. *

I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion. *

I confirm that I am not pregnant at this time, and that I have not taken Accutane within the last 6 months. I do not have a pacemaker or internal defibrillator. *

I acknowledge that I am not currently breastfeeding. I understand that certain medical treatments, procedures, or medications may have different considerations for breastfeeding individuals. I confirm that this information is accurate and understand that I should inform the healthcare provider immediately if my breastfeeding status changes. *

I understand that a 24-hour notice is required for any appointment rescheduling or cancellations. If I do not provide this notice, I agree that a $75.00 fee will be charged to my account. By signing below, I confirm my acceptance of these terms. I also agree to arrive 10 minutes early for my appointment to allow time for numbing cream application if needed, complete any necessary hair and scalp analysis, and take a moment to relax with a complimentary beverage. *

I confirm that the information provided is accurate. I understand my obligation to update LMC - Laser Medical Clinic on any relevant medical or health issues for appropriate care. By signing below, I voluntarily consent to treatment and release this establishment and its agents from any future claims related to my treatment. *

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