Your Information
First Name
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Last Name
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Email
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Phone
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Street Address
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Apartment Number / Suite Number (if applicable)
Province / State
City
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Postal code / Zip Code
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Date of birth
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How did you hear about us?
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Word of mouth
Google
Social Media
Other
Marital Status
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Single / Never Married
In a relationship
Living common-law
Married
Separated
Divorced
Widowed
Lifestyle Questions
Occupation
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When were you last exposed to the sun (including tanning booths)?
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Do you use neurotoxin (Botox) or fillers (dermal filler or lip filler):
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Yes
No
Skin type (when exposed to the sun without protection for one hour):
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Always burns, never tans
Sometimes burns/sometimes tans
Always burns, sometimes tans
Always tans
Describe your skin & your present skin care regime? What skin care product line are you currently using?
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Medical History (Please check all that apply). If none of the below apply to you, please click NONE.
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Alopecia
Anxiety/Mental Health Issues
Asthma
Burns / Skin grafts
Cancer
Cardiac Condition
Chronic Congestive Heart Failure
Chronic Cough
Diabetes
Dizziness
Eczema
Endocrine Disorders
Epilepsy
Fungus
Hair loss / Hair thinning
Herpes
HIV
Infectious Disease
Ingrown Toenails
Low blood pressure
Lupus Erythematosus
Pace Maker or Similar Device
Permanent Makeup
Phlebitis/Varicose Veins
Polycystic ovary Syndrome (PCOS)
Seizures
Shingles
Shortness of Breath
Thyroid problems
Warts
NONE
Health Background
How would you describe your overall health?
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Excellent
Good
Fair
Poor
Have you ever had an allergic reaction to a product applied to your skin?
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Yes
No
Do you have any other significant medical history or medical conditions (not listed)?
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Please list all (medical or cosmetic) past surgeries and dates.
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Please list all of the medications you are currently taking and the condition it treats:
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Are you interested in our hair restoration services?
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Yes
No
Are you on any type of hormone therapy:
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Yes
No
Please list all allergies:
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Your Goals
What do you hope to accomplish during treatment?
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Do you have a specific skin condition you wish to correct?
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When looking in the mirror, I am somewhat concerned, not concerned or very concerned about the appearance of my wrinkles.
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Not Concerned
Somewhat Concerned
Very Concerned
Your Understanding
I understand the clinical results may vary depending on individual factors, including medical history, skin and hair type, patient compliance with pre/post treatment instructions, and individual response to the treatment.
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I understand that treatment involves a series of treatments and the fee structure has been fully explained to me.
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I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion.
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I confirm that I am not pregnant at this time, and that I have not taken Accutane within the last 6 months. I do not have a pacemaker or internal defibrillator.
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I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire.
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I certify that the information above is true and correct. I understand that it is my responsibility to inform the LMC - Laser Medical Clinic of my current medical or health concerns, which are essential for proper treatment. My signature below constitutes my consent to treatment. I hereby give my consent and authorization voluntarily and release this establishment and its agents of any claims that I have or may have in the future connection with the treatment.
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