AFFORDABLE LASER HAIR REMOVAL
2022 West Northwest Hwy
Suite 120, Grapevine, Tx 76051.

  
 

 

Client Information and Health History

  
 
  Date :
  Signature :
 
 
 
Name : Date of Birth Age Gender: Male Female
Adress: City Zip State
Phone: Work#: Email:    
               
 
  How did you hear about us?  
  Client Objective: What specific areas do you want treated?  
   
  Previous Procedures:  
 
 
  • Have you ever used Retin A, Glycolic acid or Lactic Acid?
    		•  yes No
  • Have you had facial laser resurfacing or chemical peel in the last 3 months?
    		• yes No
  • Have you had facial laser resurfacing or chemical peel in the last 3 months?
    		• yes No
    Hypersensitivity & Fragility:
  • Have you ever had a skin allergy?
    		• yes No
  • What Skin products are you currently using?
    		• yes No
     
    		 
      Fitzpatrick Classification Syster: (Mark skin type below which best describes you.)  
     
        Skin Type Heredity   Characteristicics of skin
      I Caucasian/Nordic   Always burns, Never Tans
      II Caucasian   Usually Burns, Tans less than average
      III Darker Caucasian   Sometimes mild burn, Tans about average
      IV Mediterranean/Asian/Hispanic   Rarely Burns, Tans more than average
      V Middle Eastern/East Indian/Latin   Rarely burns, Tans profusely
      VI African American   Never burns, Deeply Pigmented
             
    		 
      Sun Exposure:  
         
     
    What percentages of time do you spend in the sun?       May-October: November-April:
    Do you use Sun block on regular basis? yes No    
    Do you Sunbathe or use tanning salon? yes No    
         
    		 
         
    		 
         
       
     
       
    		 
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