MEDICAL HISTORY FORM

Flawless Laser Online Medical History
Sex *
Currently on accutane or similar medications? *
Any Allergies? *
Autoimmune disease, HIV, Lupus, Hepatitis? If yes provide diagnosis date, medication dosage and frequency in details field. *
Blood Thinners - Heparin, Coumadin, Warfarin, etc? *
Breast Feeding, pregnancy or planning pregnancy? *
Cancer or post cancer treatments? If yes provide diagnosis date, medication dosage and frequency in details field. *
Cardiovascular problems, Heart ailments? If yes provide diagnosis date, medication dosage and frequency in details field. *
Current cold sores or fever blisters without pre-medication? *
Cortisone or steroid injections? *
Dental Work? (recent or pending) *
Diabetes Type 1 or Type 2? If yes provide diagnosis date, medication dosage and frequency and last HBA1C with Date in details field. *
Eczema, psoriasis? *
Currently enlarged or painful glands? *
Epilepsy? If yes provide diagnosis date, medication dosage and frequency in details field. *
Facial waxing services within 7-14 days? *
Hypertension/high blood pressure? If yes provide diagnosis date, medication dosage and frequency in details field. *
Inflammatory conditions? If yes provide diagnosis date, medication dosage and frequency in details field. *
Keloids, pigmented scars, icepick scars, new scar tissue? *
Recent laser procedures, chemical peels, dermabrasion, microdermabrasion? *
Currently on light sensitive medication? *
Lymphatic disorder, inflammation of lymph vessels, lymphedema? If yes provide diagnosis date, medication dosage and frequency in details field. *
Medications (including herb and supplements)? If yes provide dosage & frequency. *
Multiple Sclerosis? If yes provide diagnosis date, medication dosage and frequency in details field. *
Neuromuscular Disorder? If yes provide diagnosis date, medication dosage and frequency in details field. *
Pacemaker or metal implants? *
Phlebitis, varicose veins? *
Pigmented moles, warts or growths, unidentified facial growth or mark? *
Recent accident or serious injury? *
Recent surgical procedure? If yes, describe. *
Rosacea, telangiectasia/couperose? *
Recent Retin-A, Retinol usage? *
Skin abrasions or lesions? *
Seizure disorder? If yes provide diagnosis date, medication dosage and frequency in details field. *
Stage III or IV acne? *
Skin-lightening or bleaching agent? *
Current sunburn? *
Swollen or infected Tonsils? *
Thyroid conditions? If yes provide diagnosis date, medication dosage and frequency in details field. *
Under medical care for an existing or suspected condition or disease? If yes, what? *
Current viral infection, influenza? *
Other contraindications or conditions for the technician to be aware of? *
Previous adverse reaction to Latex? *
Previous adverse reaction to Aspirin? *
Previous adverse reaction to Hydrocortisone? *
Previous adverse reaction to Lidocaine? *
Have you been treated with a neuromodulator (Botox, Dysport, Xeomin, etc) before? *
Have you been treated with dermal fillers before? *
I acknowledge that I have not used Accutane or any medication of the same purpose during the last 12 months. *
I acknowledge that if I've ever had a cold sore or fever blister, I should consult with my physician or pharmacist for a pre-use medication to help avoid a possible outbreak. That medication should be used each day for two days before, same day, and two days after any laser facial treatment. *
I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or faded. Pigmentation may improve or darken with successive treatments. I acknowledge the need for a proper skin care home regimen. *
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling, which usually dissipates within 72 hours depending on skin sensitivity. *
I acknowledge that if I fail to use a minimum sunblock (SPF 30), I am more susceptible to sunburn, skin damage & hyperpigmentation. *
I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied. *
I acknowledge that I should avoid use of acid products for 1 week prior, and 1 week following any light based treatments. *
I acknowledge that I should avoid the use of Retin-A type products for a period of time recommended by my medical or skincare professional during and following the treatment. *
I acknowledge that I am not pregnant or lactating. *
I acknowledge that I have answered all questions truthfully and completely. *
I acknowledge that Flawless Laser & Body Sculpting has a 24hr cancellation policy. Cancellations with less than 24 hours notice will subject to a fee of $50 per hour for every hour of treatment time that your procedure was scheduled to require. *
I hereby expressly waive and release any and all claims which I have or may in the future have against Natasha White, Flawless Laser And Body Sculpting Inc (including their affiliates, and their respective directors, officers, employees, agents, representatives, shareholders, successors and assigns) (collectively, "Releasees"), arising out of or attributable to receiving the procedure described herein, due to any cause whatsoever, including without limitation the negligence of any Releasee, breach of contract, or breach of any statutory or other duty of care owing under occupiers liability legislation or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. *

CONTACT

Flawless Laser & Body Sculpting

12-1922 9 Ave SE

Calgary, Alberta

PH: 403-264-5200

clientcare@flawlesslaser.ca

HOURS

Mon - Fri       10:00 am - 6:00 pm

Saturday       Closed

Sunday           Closed

Closed on all statutory holidays

Flawless Laser Map

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