Name_________________________________________ Date of Birth__________________________________________ Street Address________________________________________________________________________________________ City, State, Zip________________________________________________________________________________________ Best Way to reach you__________________________________________________________________________________ Occupation___________________________________________________________________________________________ How did you hear about us?______________________________________________________________________________ What brings you in today? _______________________________________________________________________________ What’s your ethnicity? (German, Italian, Native American etc…info is needed only to determine your skin type)_______________________________________________________________________________________________ Do you have any chronic medical conditions? If yes, please list ______________________________________________________________________________________ Do you take any medications, herbal or natural supplements on a daily basis? If yes, please list______________________________________________________________________________________ Do you have any allergies to medications, latex, foods or any substances? If yes, please list______________________________________________________________________________________ Have you taken Accutane or any anticoagulants in the past 6 months? Do you have a history of cold sores, fever blisters, Herpes I or I ? Do you have a history of hypo-or hyper-pigmentation? Have you ever had any skin treatments such as laser, microdermabrasion, chemical peels, or injections? If yes, please list______________________________________________________________________________________ What skincare products are you currently using? ______________________________________________________________ Do you use any topical medications or creams such as Retin-A, Renova, Tazoraz, Dif erin, Obagi or any others? If so, please list _______________________________________________________________________________________ Do you have any tat oos or permanent makeup? If yes, please list ______________________________________________________________________________________ Have you had any sun exposure in the last 4-6 weeks, including tanning beds, tanning/bronzing creams or spray tan? Yes/No If yes, please list ______________________________________________________________________________________ What are your skin care goals?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Tell us about your skin Acne___ Large Pores____ Broken Capil aries___ Sun Damage___ Please list any additional concerns or comments about your skin __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Consent for Pulsed Light-Based Treatments I authorize ____________________________________ to perform pulsed light hair reduction or pigmented lesion or vascular lesion treatment on me. I understand that the procedure is purely elective. I understand that serious complications are rare, but possible. Common side ef ects include temporary redness, swelling and mild “sunburn” like effects that may last a few hours to 3-4 days or longer on the treated area. I understand that treatment of benign pigmented lesions and vascular lesions cannot be accomplished without producing some epidermal damage and this may take 2-4 weeks to resolve. Pigment changes (light or dark spots on the skin) lasting 1-6 months or longer may occur. In addition, freckles may lighten and/or temporarily or permanently disappear in treatment area. There is the likelihood of coincidental hair removal when treating pigmented/vascular lesions in hair bearing areas. Other potential risks include blistering, crusting, itching, whitening, pain, bruising, burns, infection, scabbing, swelling and failure to achieve the desired result. Lasers can cause eye injury and protective eyewear must be worn during treatment. I understand that sun exposure, use of tanning lamps or self-tanning creams and not adhering to the pre-and -post care instructions provided to me may increase my chance of complications. I understand the importance of having an accurate diagnosis by a physician of brown spots prior to treatment, as treatment of undiagnosed skin cancer may delay proper medical care. I understand that no guarantees, either expressed or implied, have been made to me regarding the outcome of this treatment/procedure. I consent to the photographs being taken to evaluate effectiveness. My pictures wil not be used in any way without my permission. Before and after treatment instructions have been discussed with me. The procedure as well as potential benefits and risks have been explained to my satisfaction. I have all my questions answered. I freely consent to the proposed treatment. Patient Signature ____________________________________________ Date________________________ Printed Name _________________________________________________________________________ Witness Signature __________________________________________ Date ________________________ Printed Name___________________________________________________________________________ Fitzpatrick Skin Type Worksheet
Name: Date:
What is the color
Light Blue,
of your eyes?
What is your
Sandy Red
natural hair
Dark Blond
What is the color
Very Pale
Pale with
Beige Tint
unexposed skin?
Do you have
Freckles on
Sun exposed
What happens
Never had
when you stay in Redness,
followed by
To what degree
Hardly or
Turn Dark
color Tan
turn Brown?
Do you turn
brown several
hours after sun
How does your
Never had
face respond to
a Problem
When did you last
expose yourself
More than 3
1-2 Months
Less Than
Less than
to the sun tanning
Months ago
bed or self-
tanning creams?
Do you expose
the area to be
treated to the
Fitzpatrick Skin Type:


Signature: __________________________________________ Date: ________________________


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