LASER SERVICES QUESTIONNAIRE

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Name(Required)

First Last

D.O.B(Required)

MM slash DD slash YYYY

Street Address:(Required)

City(Required)

State(Required)

Zipcode(Required)

Email(Required)

Phone(Required)

How did you hear about our services?(Required)

Reason for appointment(Required)

Have you ever had an allergic reaction to topical creams or lotions?(Required)

Yes

Are you currently under care of a dermatologist or any physician/specialist?(Required)

Yes

If yes, what type of treatment?(Required)

Have you taken antibiotics in the past two weeks?(Required)

Yes

Have you had any sun exposure in the last two weeks?(Required)

Yes

Do you get cold sores?(Required)

Yes

Do you feel your skin is sensitive?(Required)

Yes

Are you pregnant or trying to become pregnant?

Yes

Are you breastfeeding?

Yes

Are you currently being treated for an acute or chronic health condition?

Yes

If yes, please explain:

Please list all medications you are currently taking:

Allergies:

Have you had any of the following procedures/conditions?

Cosmetic surgery

Laser resurfacing

Laser Hair Removal

Botulinum (Botox) Injections

Fillers

Microdermabrasion

Collagen Injections

Chemical Peels

Extractions

Waxing

Systemic/Discoid Lupus

Dermatitis

Skin Cancer

Keloid Scarring

Polycystic Ovarian Syndrome (PCOS)

Other:

What skincare products are you using?(Required)

Cleanser

Toner

Exfoliants

Moisturizer

SPF

Serum

Other?

What are your areas of concern?(Required)

Uneven Skin Color

Acne/Breakouts

Facial Scarring

Rosacea

Enlarged Pores

Freckles/Age Spots

Fine Lines/Wrinkles

Hair Reductions

Other?

I acknowledge that all of the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and home care products to achieve the desired results. Results CANNOT be guaranteed due to individual skin types and conditions. I understand that I MUST notify my provider of any changes pertaining to the above questionnaire. I hereby release Clearwater Primary Care & Aesthetics, its operators and ALL employees from ALL liabilities associated with the procedure based upon my accuracy of information provided above.

Patient Signature(Required)

LASER TREATMENT INFORMED CONSENT

Please initial next to each of the following to acknowledge and give your informed consent:

The following adverse/side effects may occur during or after treatment:

Short term effects may include: Reddening, temporary bruising or blistering, hyperpigmentation (skin darkening), or hypopigmentation (skin lightening) have also been noted after treatment. These conditions usually resolve within 3 to 6 months, but permanent color change is a risk. Although it is rare, avoiding sun exposure before and after treatment reduces these risks(Required)

There is a slight risk of scarring. Those prone to Keloid Formation and scar easily are at a higher risk.(Required)

Infection: Although unusual, bacterial, fungal and viral infections can occur as a result of treatment and non intact skin barrier. Herpes Simplex Virus infections around the mouth can occur following a treatment. This applies to both individuals with and without a history including open lesions from active infections(Required)

Exposure of eyes to the laser light could harm vision: Clients must keep eyes closed and keep eye protection on during treatments(Required)

I have read this form in its entirety and have been informed that not reading the consent form and signing it does not excuse any terms or conditions described. As I have signed acknowledging my financial and personal responsibility to comply.(Required)

Noncompliance with pre and post care instructions and guidelines puts the clients at an increased risk for unwanted results. including but not limited to: delay in healing, changes in skin pigmentation and scarring(Required)

Technical Difficulty: Occasionally unforeseen mechanical problems may occur and your appointment may need to be rescheduled. Every effort will be made to notify you prior to your arrival to the office. We do apologize for any inconvenience this may cause.(Required)

Gratuity Policy: Please note that 15-20% gratuity for excellent service is customary for all spa services including laser hair removal. Please note Groupon purchases or other “Special Deals” do not include your provider’s gratuity.(Required)

Acknowledgement

All of my questions regarding the procedure have been answered satisfactorily. I understand the procedure and I accept the risks. I hereby release Clearwater Primary Care & Aesthetics, its operators and ALL employees from ALL liabilities associated with the procedure

Patient/Guardian Signature(Required)

Technician Signature

NO SHOW/MISSED APPOINTMENT POLICY

We, at Clearwater Primary Care & Aesthetics understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least a 24 hour notice). You can cancel appointments by calling the following number: 727-446-7478.

To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled to attend their visit on time. As a courtesy, an appointment reminder call to you is made/attempted one (1) business day prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time

PLEASE REVIEW THE FOLLOWING POLICY:

Please cancel your appointment with at least a 24 hours’ notice: There is a waitlist to see the clinicians at Clearwater Primary Care & Aesthetics, and whenever possible, we like to fill canceled spaces to shorten the waiting period for our patients.
If less than a 24 hour cancelation is given, this will be documented as a “No-Show” appointment.
If you do not present to the office for your appointment, at your appointment time, this will be documented as a “No-Show” appointment.
Each No-Show appointment will result in a $50.00 No-Show fee to you, this fee will need to be paid prior to seeing a provider at a future appointment.
If you have 2 “No-Show/Missed” appointments within a one-year time period, you will receive a warning letter from our office.
If you have 3 “No-Show/Missed” appointments within a one-year time period, dismissal from the practice will be considered. *You will be notified by letter if the dismissal was approved.

I have read and understand Clearwater Primary Care & Aesthetics No-Show/Missed Appointment Policy and understand my responsibility to plan appointments accordingly and notify Clearwater Primary Care & Aesthetics appropriately if I have difficulty keeping my scheduled appointments.

Patient Signature(Required)

This form is to serve as consent to add any communication, including text messages, emails, and photos, to your patient chart. We will also notate any phone conversations regarding treatment. This will help us to give the best treatment possible

Thank you for your cooperation

Patient Signature(Required)

Laser Services Questionnaire