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Laser business forms c.indd

Name: _________________________________________________ Date of Birth: ______________________________________ Address: ___________________________________________________________________________________________________ City ________________________________________________________________ State ________________ Zip: ____________ Email: _________________________________________________ Today’s Date: ______________________________________ Home Phone:____________________________________________ Business Phone:____________________________________ Cell # or Preferred Contact #: _______________________________ Is it important to be discrete?__________________________ How did you hear about us? ____________________________________________________________________________________ Describe the nature of your visit? ________________________________________________________________________________ ___________________________________________________________________________________________________________ What are your expectations?____________________________________________________________________________________ ___________________________________________________________________________________________________________ Please fill out any of the following that may apply:
Have you been on Accutane in the past 6 months?_______________ Include any other medications that make you photo sensitive (antibiotics): _______________________________________________ Have you taken doxycycline, minocin, minocycline, or vibramycin recently? When?_______________________________ ___________________________________________________________________________________________________________ List all medications you are currently taking (blood thinners, herbs, supplements, vitamins, aspirin etc.): _______________________ ___________________________________________________________________________________________________________ Have you ever had allergic reactions to: Food Latex Nickel Aspirin Lidocaine Hydrocortisone Hydroquinone/Bleaching Agents Other______________________________________ Are you currently under the care of a physician? If so, what for? _______________________________________________________ ___________________________________________________________________________________________________________ Any Allergies: _______________________________________________________________________________________________ ___________________________________________________________________________________________________________ Acne:
Do you have a history of breakouts? Yes No
If so, what is the frequency of your breakouts? Frequent Occasional Rarely
Do you experience cystic breakouts? Yes No
Do you have any scarring as a result from your acne? Yes No
Skin Background:
Skin Disease: ______________________________________ Lesions: _____________________________________________ Chronic Rash: ______________________________________ Melanoma: __________________________________________ Surgical Scars: _____________________________________ Psoriasis: ____________________________________________ Hairy Moles:_______________________________________ Are you currently under the care of a dermatologist? If so, for what? ____________________________________________________Have you had prolonged sun exposure (or tanning bed) in the past 3 days? Yes NoIf so, are you currently sunburned? Yes NoDo you use tanning beds? Yes NoAre you using chemical tanning solutions? Yes NoDo you use sunscreen on a regular basis? Yes NoHave you waxed, used depilatories, bleaches or other chemical processes? ________________________________________How much water do you normally consume daily? __________________________________________________________________ Have you had Botox or Collagen injections in the past 6 months? Yes No If yes, and less then 3 months, approximate dates and location. ________________________________________________________Do you use topical ointments? Retin-A Glycolic Lactic Acid Hydroquinone Other: ___________________________What type of skin care products are you using? _____________________________________________________________________ ___________________________________________________________________________________________________________ Check other services of interest:
Laser Hair Removal (list different areas) ________________________________________________________________________ Laser Vein Removal Non-ablative LaserFACIAL Pigmented Lesions or Brown Spot Removal Other: ________________ I certify that the above medical history information is accurate and correct:
Patient Signature: ________________________________________ Date:_____________________________________________ DR/Tech Signature:_______________________________________ Date:_____________________________________________

Source: http://www.lrhrc.com/assets/patient_medical_history.pdf

Tus9 - aanvullende informatie - 2012

Aanvullende reisinformatie voor uw reis naar Turkije actiereis 2e gratis! Gefeliciteerd met uw boeking! Hieronder vindt u praktische informatie over uw reis. Deze informatie hoort bij de uitgebreide reisbeschrijving die u kunt vinden op onze website www.summum.nl Algemene landeninformatie Turkije Oppervlakte Taal De officiële taal in Turkije is Turks. Het Turks stamt uit het s

moot.org.uk

The Round TableVol. 96, No. 388, 3 – 28, February 2007Fiji is suspended from the Commonwealth after a military coup. Peace talksprogress in Uganda and flounder in Sri Lanka. Pakistan’s fragile alliance with the West ishighlighted when President Musharraf is simultaneously praised for fighting terror in the USAand blamed for supporting extremists in the UK. A major terrorist alert at UK ai

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