Laser Treatment Consultation Form

Skin Typing Evaluation and Patient Evaluation Form

This information will help your esthetician to better evaluate your skin type so that your laser treatment will be more effective. Skin type is determined genetically includes the color of your eyes, hair, etc. The way your skin responds to sun exposure is another way of correctly assessing your skin type. Recent tanning, whether by sun or an artificial tanning booth, even tanning creams, can have a major impact on your skin.

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Genetic Disposition

The number you see next to each option corresponds to its score.

Natural Eye Color

Natural Hair Color

Color of non-exposed Skin

Do you have freckles on unexposed skin?

Total Score for Genetic Disposition

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Reaction to Sun Exposure

The number you see next to each option corresponds to its score.

What happens when you stay in the sun for a prolonged time?

Degree that you turn brown ?

Do you turn brown within several hours after sun exposure?

How does your face react to the sun?

Total Score for Sun Exposure

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Tanning Habits

The number you see next to each option corresponds to its score.

When did you last expose your body to sun or tanning booth or tanning cream(s)?

Have you expose the are being treated today to the sun?

Total score for tanning habits

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Summary:

Score for Genetic Disposition

Score for reaction to Sun Exposure

Score for Tanning Habits

Total Skin type score

Signature

Date

Esthetician Signature

Date:

Laser hair Removal Policy and Guideline Consent

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I, _______________________________, am aware that there is a specific guideline for laser hair removal at Columbia Laser & Aesthetics that I will need to follow as listed below to obtain permanent hair reduction.

Name:

Please thoroughly read and initial beside each statement:

I understand that my esthetician recommends a minimum of 9 laser hair removal treatments per area for all patients (regardless of any previous treatments at another facility) for best results. I understand that laser treatments are sold in packages of 3.

I understand that only after I have paid for and received all 9 treatments per area at Columbia Laser & Aesthetics am I eligible to receive a maximum of 3 complimentary follow up appointments.

I understand that to see optimum results I will need to stay on a consistent schedule as advised by my esthetician (typically 4 weeks for smaller body parts, or 8 weeks for larger body parts) I am aware that if I do not stay on the schedule my esthetician recommends, I will not see results.

I understand that I am not to have any prolonged exposure to the sun or use any form of tanning (including self-tanners, spray tans, and tanning beds) 2 weeks before and/or 2 weeks after each of my scheduled appointment dates. I am aware that failure to avoid sun or tanning can result in adverse reactions such as hyper/hypopigmentation and/or burning of the exposed area(s).

I understand that I will not be able to have laser hair removal treatments if I have been on an antibiotic or have been taking any medications with a photo/sun-sensitivity within the past 10 days (you will need to be scheduled for 10 days after the last day of taking such medications).

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Signature

Date

Email Address: laritz@laritzspasalon.com

Phone Number: (770) 918-1380

Toll Free: (833) 953-1380
Mon-Sat: 10:00am-7:00pm, Sunday: Closed

Address: 905 Flat Shoals Rd SE, Conyers, Ga 30094

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Laser Treatment Consultation Form

Skin Typing Evaluation and Patient Evaluation Form

Laser hair Removal Policy and Guideline Consent

Laser Treatment Consent Form

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