Intakeform

Intakeform
Client details (all information is treated confidentially)
Full name

First nameLast name
Adress

Street

Housenummer

CityProvince

Postalcode
Date of birth

MaandDagJaar
Birthday
Phone number
E-mail
example@gmail.com
Medical health
Do you suffer or have you suffered from one or ore of the following diseases?

Disease of the (ad) kidneysAllergies, such as photosensitivity or histamine reactionsBlood or clotting disorders, such as thrombosisEndocrinological diseases, such as diabetesHeart disease, such as high blood pressureSkin and/or venereal diseases, such as herpes, psoriases, eczema, keloid formationCancer or skin tumorsImmune diseases, such as a weakened immune systemInfectious diseases of inflammationVaricose veins or other vascular problemsHormone imbalance, such as decreased estrogen levels, increased androgenNervous system diseases, such as epilepsyOther
If one or more of the above contra-indications apply to you, you have an increased risk of skin reactions, any skin reaction, as a result of the laser treatments.
Are you taking or have you taken any medications, birth control , antibiotics and aspirin overuse?

NoYes:
Do you have a pacemaker, implants, protheses of other foreign objects?

NoYes:
Do you use homeopathic remedies or herbel extracts, such as St. John's wort?

NoYes:
Are you regularly exposed to sunlight, sunbeams or do you use self-tanning products?

NoYes:
Do u have permanent make-up or a tattoo?

NoYes:
Do you have botox or fillers?

NoYes:
Does your skin have irregularities in structure or pigment, such as pigment spots?

NoYes:
Are you undergoing treatments that make your skin more sensitive, such as a peeling?

NoYes:
Are you pregnant or are you breastfeeding?

NoYes:
Have you ever had a hair transplant?

NoYes:
Hair color
What is your hair color on you body of the uncovered parts, for example arms of legs? Choose from one of the hair colors below:

BlondRedDark blondeLight brownBrownDark brownBlack
What is your hair color on you body of the covered parts, for example belly, armpits, back, bikini? Choose from one of the hair colors below:

BlondRedDark blondeLight brownBrownDark brownBlack
Skin Type en Skin Care
Which skin type suits you best?

Skin type 1: Sunburns very quickly and does not tan.Skin type 2: Sunburns fairly quickly and Tans only slowly. Therefore, it remains sensitive to sunburn.Skin type 3: Tans easily, can burn at the beginning of the summer season if you sunbathe for too long, but hardly any more after tanning.Skin type 4: Almost never Burns and Tans very well. Usually naturelle brown skin.Skin type 5: A Southern European type, never burns.Skin type 6: Black skin.
Where are your parents originally from?
Are you currently using any skin care products?

NoYes:
Conditions
You are aware that:

1. The treatment takes place at your own risk;

2. The number of treatments required cannot be estimated accurately;

3. We do not guarantee the result of the laser treatments. Even though we use the best laser technology on the market with the Soprano Titanium and the Gentle Max Pro Plus, each person responds differently to the laser treatment;

4. The skin must not be damaged on the area to be treated, otherwise it cannot be treated here.

5. Redness may occur after treatment. This disappears within 2 days;

6. There is a risk of hyperpigmentation/hypopigmentation. This risk can be greatly reduced by using a good sunscreen with SPF 50;

7. With the Soprano Titanium you may not expose the treated areas to the sun for 10 days before and after the treatment. With the Gentle Max Pro Plus you are not allowed to expose the treated areas to the sun for 6 to 8 weeks before and after the treatment. It also applies to the use of the tanning bed and self-tanning products, do not use them with the Soprano Titanium 10 days before and after the treatment. With the Gentle Max Pro Plus is it also 6 to 8 weeks;

8. There may be a number of causes for new hair development, namely: disturbances in the hormonal balance, certain medications or diseases, puberty, pregnancy, breastfeeding and menopause;

9. You are obliged to wear laser goggles at all times during the treatment to prevent possible damage to the eyes;

10. You must cancel the appointment at least 24 hours in advance if you are unable to attend. If you do not do this, The Laser Lab reserves the right to charge costs for this. This amounts to 50% of the treatment that would be on the day of your appointment.
I will let you know at least 24 hours in advance if appointments cannot take place, so that the practitioner can book another client. If I do not cancel my appointment at least 24 hours in advance, I agree that The Laser Lab can charge costs for this.

AgreeRefused
This agreement applies to this treatment and all future treatments. I will inform the practitioner if my medical history changes and this may affect the treatment.

AgreeRefused
The Laser Lab processes your personal data for the following purposes: To be able to call or e-mail you if necessary. To inform you about changes to our services. To approach you if we have any questions.
I have completed this form completely honestly.

NoYes
Date of today

DagMaandJaar
Signature

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Intakeform

Medical health

Hair color

Skin Type en Skin Care

Conditions