Medical Consent Form

Medical History Form

First Name:*
Last Name:*
Address*
City*
Postal Code: Requires space (eg L1L 1L1)*
Cell:
Work Phone
Home Phone*
Email Address*
Birthday:*
MM slash DD slash YYYY
Age*
Referred By:*
Treatment Areas:*
1. Current or history of cancer, especially malignant melanoma or recurrent non-melanoma skin cancer, or pre-cancerous lesions such as multiple dysplastic nevi.*
- Yes
- No
2. Any active infections.*
- Yes
- No
3. Diseases which may be stimulated by light at 515 nm to 1200 nm, such as history of recurrent Herpes Simplex, Systemic Lupus Erythematosus (autoimmune disease) or Porphyria.*
- Yes
- No
4. Use of photosensitive medication and/or herbs that may cause sensitivity to 515 – 1200 nm light exposure, such as Isotretinoin, tetracycline, St. John’s Wort or Beta-creatine.*
- Yes
- No
5. Immunosuppressive diseases, including AIDS and HIV infection, or use of immunosuppressive medications.*
- Yes
- No
6. Do you use Accutane, Retin-A, Renova, Adapalene or any other prescription skin products?*
- Yes
- No
In the last 6 months?*
- Yes
- No
7. Patient history of Hormonal or endocrine disorders, such as polycystic ovary syndrome or diabetes, unless under control.*
- Yes
- No
8. History of bleeding coagulopathies (also called clotting disorder and bleeding disorder), or use of anticoagulants?*
- Yes
- No
9. History of keloid scarring (Keloids are the result of an overgrowth of dense fibrous tissue that usually develops after healing of*
- Yes
- No
10. Very dry skin?*
- Yes
- No
11. Exposure to sun or artificial tanning during the 3-4 weeks prior to treatment?*
- Yes
- No
12. List any medications, supplements, vitamins, etc. that you take regularly (including aspirin)?*
13. Are you taking oral contraception?*
- Yes
- No
14. Are you pregnant or trying to get pregnant?*
- Yes
- No
Are you lactating?*
- Yes
- No
15. Do you exercise regularly?*
- Yes
- No
16. List any Allergies:*
17. Have you had Botox in the last 2 weeks in the area to be treated?*
- Yes
- No
Skin type (when exposed to the sun without protection for about 1 hour)*
- always burns but never tans
- always burns but sometimes tans
- sometimes burns but sometimes tans
- always tans
What is your ethnic background?*
When were you last exposed to the sun (including tanning booth)?*
Do you use chemical sun tanning lotions?*
- Yes
- No
Are you planning a holiday in the sun?*
- Yes
- No
If yes, when are you going?*
What SPF sunscreen do you use on your face?*
What SPF sunscreen do you use on your body?*
What is your pain threshold?*
- low
- medium
- high
Reason for visit (area to be treated)*
Prior treatment (if any)*
I duly authorize GLO LASER to perform the Soprano Laser

Laser Hair Removal procedure and any other measures, which in their opinion may be necessary.

I understand that the Soprano is a device used for laser hair removal and that clinical results may vary in different skin types and hair types. I understand there is a possibility of short-term effects such as reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me
(patient's initials)*
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 treatment. I understand that epilation with the soprano system is a safe alternative to methods used for removing unwanted hair, such as shaving, waxing, chemical epilation and electrolysis.

I understand that treatment by the Soprano laser hair removal system involves a series of treatments and the fee structure has been fully explained to me
(patient's initials)*
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 base solely on my expressed desire to do so.

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.

I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.

In the event that you wish to cancel or reschedule an appointment you MUST give at least 24 hours notice. If you cannot provide 24 hours notice you will be charged 50% of the service you cancelled/rescheduled.
(patient's initials)*
If you miss your scheduled appointment a credit card will be required to book any further appointments.
Opt into Monthly promotional newsletter? Follow us on Facebook or Twitter for monthly promos and Contests!*
- Yes
- No
Please Note: A fee will be charged for missed appointments - 30 min appt. missed $25 fee with credit card on file to rebook - 1 hour appt. missed $50 fee with credit card on file to rebook, 2 hour plus a $75 fee with credit card on file to rebook.
*
- Agree
Signature*
Date*
DD slash MM slash YYYY

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Medical History Form

GLO LASER OAKVILLE