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1. Date
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Treatment Number
|
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Procedure
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Area Treated
|
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Laser
|
WvLgth
|
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PulseW
|
Energy
|
|
Spot
|
Cooling
|
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# Pulses
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Notes
|
|
|
|
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2. Date
|
Treatment Number
|
|
Procedure
|
Area Treated
|
|
Laser
|
WvLgth
|
|
PulseW
|
Energy
|
|
Spot
|
Cooling
|
|
# Pulses
|
Notes
|
|
|
|
|
3. Date
|
Treatment Number
|
|
Procedure
|
Area Treated
|
|
Laser
|
WvLgth
|
|
PulseW
|
Energy
|
|
Spot
|
Cooling
|
|
# Pulses
|
Notes
|
|
|
|
|
4. Date
|
Treatment Number
|
|
Procedure
|
Area Treated
|
|
Laser
|
WvLgth
|
|
PulseW
|
Energy
|
|
Spot
|
Cooling
|
|
# Pulses
|
Notes
|
|
|
|
|
Payment Plan
|
|
|
per tx / pkg price-
|
tx
|
|
per tx / pkg price-
|
tx
|
|
per tx / pkg price-
|
tx
|
|
per tx / pkg price-
|
tx
|
|
Notes
|
|
|
|
|
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Personal Medical History
|
|
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How did you hear about us?
|
PLC Referring Client
|
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Present Medications
|
|
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Have you ever taken Accutane?
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If yes, please mention date of last dose taken
|
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Medication Allergies
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|
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General Medical History
• • •
|
Comments on any of the above selections?
|
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Any Implants/Injectables/Permanent Make-up?
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If so, please list with dates
|
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On mood altering/anti-depression medication?
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|
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Surgical procedures/dates
|
|
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Is thyroid function normal?
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Explain
|
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Changes in weight or voice?
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Explain
|
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Menstrual cycle every___days
|
|
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Pregnancies
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Deliveries
|
|
Are you currently pregnant?
|
|
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If post menopausal, give date of last menses
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increase/decrease of hair?
|
|
Hysterectomy?
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Date
|
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Ovaries Removed?
|
increase/decrease of hair?
|
|
Every had a hormone level test?
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Dates/Results
|
|
Ever inform your doctor of your hair growth?
|
Response
|
|
Please rate your skin type
• • •
|
|
|
Ever had any laser treatments done before?
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If so, what have you had done?
|
|
Treatments you are interested in
• • •
|
Ever experienced/currently use/used any of these
• • •
|
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Area you are interested in having treated?
• • •
|
|
