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Dolcevitasalon.com

Laser Hair Removal Consultation
Personal Information
Name: _____________________________________ Home Phone: ________________________ Address ____________________________________ Work/Cell Phone: ______________________ City:_________________________________ State: ____________ Zip Code: _________________ Date of Birth: _______________________ Referred by: __________________________ Sex: F M Email: _____________________________________________________________________________ Medical History
Bleeding disorder, bruise easily: _____________ Endocrine / hormone issues: _______________ Pigmentation disorder: ____________________ Pacemaker / defibrillator: __________________ History of cold sores: ______________________ Accutane within 6 months: _________________ History of keloid scarring: __________________ History of skin cancer: _____________________ Dermatological conditions:_________________ Photoallergic: ____________________________ List any medications taken:________________________________________________________________ Medical conditions:______________________________________________________________________ List any allergies:________________________________________________________________________ Contraindications:
• Any abnormal or undiagnosed pigmentation should be avoided • Non-intact skin (ie. sores, psoriasis, eczema, infection, rash) should be avoided • Recent chemical or mechanical peeling in treatment area (within 2 weeks) • Laser resurfacing in treatment area within 3 months • Any medical condition involving impairment of skin structure, esp healing patterns
Precautions
: (treat with caution if patient has any of following risk factors)
• Medications that may cause photosensitivity to light 650-950 nm • History of skin cancer in treatment area, family history of melanoma Skin Type Assessment
Last exposed to UV (sun or tanning bed)________________________________________________________ Passive tan?_______________________________ Self-Tanning lotion?______________________________ Epilation History
*You must wait 6 weeks fol owing any of the above epilation methods before commencing laser hair removal treatment. Hair Assessment
Areas to be treated________________________________________________________________________ Hair color_________________________________ Hair density_________________/ cm2______________ *Baseline photos and/or photo documentation is recommended. Possible Side Effects:
• Temporary mild discomfort from treatment • Temporary swelling, redness in treatment area • Superficial scabbing, crusting or blistering • Transient or permanent dyschromia following epidermal injury
Treatment Schedule:

Average number of treatments for satisfactory clearance: 4-6

*the above data is a statistical average. Some patients may require less than average or more than average number of treatments to achieve satisfactory clearance. Response to treatment varies depending on medical factors, and skin and hair types. There is also a small percentage of idiopathic non-responders. *poor target hair such as light or fine hair typical y takes twice the number of treatments than pigmented hair Informed Consent
Soprano Laser Hair Removal
Patient’s Name: _____________________________________________________ Treatment Sites: ____________________________________________________ I duly authorize Dolce Vita Salon & Spa to perform the Soprano Laser Hair Removal procedure and any other measures which in their opinion may be necessary. I understand that the Soprano is a device used for laser hair removal and that clinical results may vary in different skin types and hair types. I understand there is a possibility of short-term effects such as reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me. _______ 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 treatment. I understand that epilation with the Soprano system is a safe alternative to methods used for removing unwanted hair, such as shaving, waxing, chemical epilation and electrolysis. I understand that treatment by the Soprano laser hair removal system involves a series of treatments and the fee structure has been ful y explained to me _______ (Patient’s initials) 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 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 certify that I have been given the opportunity to ask questions and that I have read and fully understand the Patients’s Signature: ______________________________________ Date:_____________ Soprano Treatment Record
Client name: __________________________________________________________________ Session #:
Treatment area:
Fluence J/cm2:
Pulse duration msec:

Source: http://www.dolcevitasalon.com/LHR_Consultation_Questionnaire_Consent.pdf

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Asthma Action Plan PROVIDER INSTRUCTIONS At initial presentation, determine the level of asthma severity Asthma severity and asthma control include the domains ● Level of severity is determined by both impairment and risk and is assigned to the most severe category in which ➡any feature occurs. of current impairment and future risk. At subsequent visits, assess control to

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