MEDICAL HISTORY FORM Flawless Laser Online Medical History First Name * Last Name * Date of Birth * Address * City * Province * Postal Code * Sex * Male Female Age Phone * Email * Alberta Health Care ID Currently on Accutane, Epuris, or similar medications? * Yes No Details (optional) Any Allergies? * Yes No Details (optional) Autoimmune disease, HIV, Lupus, Hepatitis? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Blood Thinners - Baby Aspirin, Heparin, Coumadin, Warfarin, etc? * Yes No Details (optional) Breast Feeding, pregnancy or planning pregnancy? * Yes No Planning Details (optional) Cancer or post cancer treatments? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Cardiovascular problems, Heart ailments? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Cold sores or fever blisters without pre-medication? * Yes No If Yes, what is the most common cause of your cold sores? eg: sun exposure, immune response, etc Cortisone or steroid injections? * Yes No Details (optional) Dental Work? (recent or pending) * Yes No Details (optional) Diabetes Type 1 or Type 2? If yes provide diagnosis date, medication dosage and frequency and last HBA1C with Date in details field. * Yes No Details (optional) Eczema, psoriasis? * Yes No What area? (optional) Currently enlarged or painful glands? * Yes No Details (optional) Epilepsy? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Facial waxing services within 7-14 days? * Yes No Details (optional) Hypertension/high blood pressure? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Inflammatory conditions? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Keloids, pigmented scars, icepick scars, new scar tissue? * Yes No Details (optional) Recent laser procedures, chemical peels, dermabrasion, microdermabrasion? * Yes No Details (optional) Currently on light sensitive medication? * Yes No Details (optional) Lymphatic disorder, inflammation of lymph vessels, lymphedema? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Medications (including herb and supplements)? If yes provide dosage & frequency. * Yes No Details (optional) Multiple Sclerosis? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Neuromuscular Disorder? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Pacemaker or metal implants? * Yes No Details (optional) Phlebitis, varicose veins? * Yes No Details (optional) Pigmented moles, warts or growths, unidentified facial growth or mark? * Yes No Details (optional) Recent accident or serious injury? * Yes No Details (optional) Recent surgical procedure? If yes, describe. * Yes No Details (optional) Rosacea, telangiectasia/couperose? * Yes No Details (optional) Recent Retin-A, Retinol usage? * Yes No Details (optional) Skin abrasions or lesions? * Yes No Details (optional) Seizure disorder? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Stage III or IV acne? * Yes No Details (optional) Skin-lightening or bleaching agent? * Yes No Details (optional) Current sunburn? * Yes No Details (optional) Swollen or infected Tonsils? * Yes No Details (optional) Thyroid conditions? If yes provide diagnosis date, medication dosage and frequency in details field. * Yes No Details (optional) Under medical care for an existing or suspected condition or disease? If yes, what? * Yes No Details (optional) Current viral infection, influenza? * Yes No Details (optional) Other contraindications or conditions for the technician to be aware of? * Yes No Details (optional) Previous adverse reaction to Dairy? * Yes No Previous adverse reaction to Aspirin? * Yes No Previous adverse reaction to Hydrocortisone? * Yes No Previous adverse reaction to Lidocaine? * Yes No Have you been treated with a neuromodulator (Botox, Dysport, Xeomin, etc) before? * Yes No If Yes, date and area of last treatment Have you been treated with dermal fillers before? * Yes No If Yes, date and area of last treatment What is your primary interest for skincare treatment? (eg: skin rejuvenation, acne, hyper-pigmentation, lines, wrinkles, etc) * Specify your areas of concern. (eg: eyes, forehead, body, etc) * I acknowledge that I have not used Accutane or any medication of the same purpose during the last 12 months. * Yes No 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. * Yes No 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. * Yes No I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling, which usually dissipates within 72 hours depending on skin sensitivity. * Yes No I acknowledge that if I fail to use a minimum sunblock (SPF 30), I am more susceptible to sunburn, skin damage & hyperpigmentation. * Yes No I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied. * Yes No I acknowledge that I should avoid use of acid products for 1 week prior, and 1 week following any light based treatments. * Yes No 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. * Yes No I acknowledge that I am not pregnant or lactating. * Yes No I acknowledge that I have answered all questions truthfully and completely. * Yes No 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 agree I hereby expressly waive and release any and all claims which I have or may in the future have against Flawless Laser And Body Sculpting Inc (including their contractors, 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. * I agree If you are human, leave this field blank. Submit CONTACT Flawless Laser & Body Sculpting12-1922 9 Ave SECalgary, Alberta PH: 403-264-5200 clientcare@flawlesslaser.ca HOURS Mon - Fri 10:00 am - 6:00 pmSaturday ClosedSunday ClosedClosed on all statutory holidays YOU'LL ALSO FIND US HERE FACEBOOK TWITTER INSTAGRAM YELP Botox and Dysport NeuromodulatorsLip Fillers | Dermal FillerLaser Hair RemovalNon-Surgical Face-LiftLaser Skin ResurfacingFlawless MMP Dermal Perfusion™Body Sculpting TreatmentsLaser Tattoo RemovalOur PoliciesLaser Skin RejuvenationAbout us across the WebContact Us