Laser Hair Removal - Customer Consultation form 2 - LMS CLINIC Staff only - LMS Clinic

Customer Health Declaration - Part 2 (LMS Clinic Use)

To be completed by LMS Clinic staff only

How does your skin respond to midday summer sun exposure with no sunscreen?

Skin type 1 - Always burns, never tans

Skin type 2 - Easily burns, eventually gets a moderate skin

Skin type 3 - Sometimes burns, quickly gets an average tan

Skin type 4 - Rarely burns, quickly gets a deep tan

Skin type 5 - Very rarely burns, consistent tan

Skin type 6 - Never burns, consistent tan

Do you currently have a real or fake tan?

Yes

How long ago was your last UV Exposure?

Where did you hear about LMS Clinic?

The information I have given is correct to the best of my knowledge and I have not withheld any known medical condition. I will inform the laser operator before treatment if there has been any changes to my health (medication, pregnancy etc)

I understand that the results from this treatment vary considerably, and a small percentage of people will require more sessions to achieve satisfactory results.

I understand there is no guarantee of permanent results and maintenance treatments may be necessary.

I understand I must avoid sun exposure on the treated area for the duration of the treatment (and up to 1 month afterwards) or use a high sun protection factor to avoid sun damage.

I understand that there may be short-term side effects such as reddening or mild burning, hypo-pigmentation or hyper-pigmentation.

I understand that I must wear protective eye goggles during my treatment.

I agree that my contact details can be used to be kept updated about special offers and other information about LMS Clinic and its services that might be of interest.

I certify that I have read and understood all the information and my questions have been answered before signing this consent form. I consent to the terms of this agreement.

Print Client Name

Print Operator Name

Client Signature

Sign Here

Operator Signature

Sign Here

For Women

For Men

For Women

For Men

Health declaration form
Part 2 - LMS Clinic Staff Use

To be completed by LMS Clinic staff only

For Women

For Men

For Women

For Men

Health declaration form Part 2 - LMS Clinic Staff Use

To be completed by LMS Clinic staff only

Full Body Package 3

Full Body Package 3

Full Body Package 1

Full Body Package 1

Upper or Lower Legs

Upper or Lower Legs

Full Legs

Full Legs

Nipple Area (Areolar)

Nipple Area (Areolar)

Full Arms

Full Arms

Upper or Lower Arms

Upper or Lower Arms

Underams

Underams

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Full Face

Chin & Jaw

Upper Lip

Hollywood Bikini Line

Bikini Line

Brazilian Bikini Line

Hollywood Bikini Line

Brazilian Bikini Line

Bikini Line

Health declaration form
Part 2 - LMS Clinic Staff Use