Laser Treatment Client Intake Survey
Please complete this survey to help us ensure your safety and satisfaction with your laser treatment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you had laser treatments before?
*
Yes
No
What is your primary goal for laser treatment?
*
Please Select
Hair removal
Skin rejuvenation
Pigmentation correction
Acne/scar treatment
Other
Do you have any of the following conditions? (Check all that apply)
*
Pregnant or breastfeeding
Active skin infection or rash
History of keloid scarring
Photosensitivity
Taking blood-thinning medications
None of the above
Other
Please indicate your skin type (Fitzpatrick Scale)
*
Type I: Very fair, always burns, never tans
Type II: Fair, usually burns, sometimes tans
Type III: Medium, sometimes mild burn, tans uniformly
Type IV: Olive, rarely burns, tans easily
Type V: Brown, very rarely burns, tans very easily
Type VI: Black, never burns, deeply pigmented
Please rate your understanding of the laser treatment process
*
1
2
3
4
5
Are you currently taking any medications or have any allergies? If yes, please specify.
Is there anything else we should know about your health or skin condition?
Signature
*
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