Your Information

Marital Status *

Single / Never Married

In a relationship

Living common-law

Married

Separated

Divorced

Widowed

Lifestyle Questions

Do you or have you ever smoked? *

Current smoker

Former smoker

Non-smoker

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

Health Background

Do you have any other significant medical history or medical conditions (not listed)? *

How would you describe your overall health? *

Excellent

Good

Fair

Poor

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

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

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

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 understand that treatment involves a series of treatments and the fee structure has been fully explained to me. *

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 certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire. *

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. *

Clear