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									                         CLIENT INFORMATION AND MEDICAL HISTORY
So we may provide you with the most appropriate treatment, please complete the following questionnaire. All
information is strictly confidential.

PERSONAL HISTORY

Client’s name:________________________________________Today’s date:___________________

Date of birth:__________________Occupation:__________________________________________

Home address:_____________________________City/State/Zip code:________________________

Home phone: ________________Work phone:________________E-mail:_____________________

Emergency contact name and phone:__________________________________________________

How were you referred to us? Personal referral:____________________
Internet promotion:____________________ Other:_________________

Treatment desired:____________________

MEDICAL HISTORY

Are you currently under the care of a physician? Y___N___

If yes, for what?:_____________________________________________________________________

Do you have a history of skin rash caused by exposure to heat or infrared radiation? Y___N___

Do you have any of the following medical conditions? (please check all that apply)
   o Cold sores                                          o Cancer
   o HIV/AIDS                                            o Diabetes
   o Keloid scarring                                     o High blood pressure
   o Skin disease/Lesions                                o Herpes
   o Seizure disorder                                    o Arthritis
   o Hepatitis                                           o Hormone imbalance
   o History of hyper/ hypopigmentation                  o Blood clotting abnormalities
   o Thyroid imbalance                                   o Other__________________________
   o Any active infection                                o
Have you ever had an allergic reaction to any of the following? (please check all that apply and describe your
reaction)

Food___Latex___Aspirin___Lidocaine___Hydrocortisone___Hydroquinone___Metals___

Explain:______________________________________________________________________________

MEDICATIONS

What oral medications are you taking presently? Birth control pills___Hormones___
Others (please list)______________________________________________________________________

Are you using any mood altering or anti-depression medication?_________________________________

What topical medications or creams are you currently using? Retin-A___Others____________________

What herbal supplements do you use regularly?______________________________________________

Has any recent tanning or sun exposure changed the color of your skin? Y___N___

Have you recently used any self-tanning lotions or treatments? Y___N___

FEMALE CLIENTS

Are you pregnant or trying to become pregnant? _____________________________________

Are you breastfeeding?_______________________________________________________________

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that
it is my responsibility to inform the technician of my current medical or health conditions and to update this
history. A current medical history is essential for the caregiver to execute safe and appropriate treatment
procedures.

Signature:______________________________________________             Date:________________________
                                          CANCELLATION POLICY

In order to be considerate of other clients and use business hours more efficiently, Althea Medspa reserves the
right to enforce a cancellation policy. While consideration will be given to extenuating circumstances, we ask
that you give us 24 hours notice if you cannot make your appointment.

I understand that the full value of the scheduled treatment will be charged to my credit card (if a credit card is
not available, a bill will be mailed out.) if I do not show up for my appointment and/or if I do not call to
reschedule within 24 hours of my original appointment time.


                                               REFUND POLICY

There are no refunds on vouchers, packages, or gift certificates. If a laser package has been prepaid and a client
chooses to discontinue treatment, the remaining credit can be applied toward other services.

If medical conditions restrict a client’s treatment program, their account will be placed on hold until they can
continue services.

For any and all other situations where refunds are requested, the return or credit is left at the sole discretion of
the management.

Althea Medspa makes no guarantee on any service as results can vary from one client to the next.

Your signature below is an agreement to and understanding of our cancellation and refund policies.


Signature:______________________________________________                Date:________________________
                                  Informed Consent for Laser Services
The following problems may occur with laser treatment.

    1. However slight, there is a risk of scarring. _____ (initial)

    2. Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-
        pigmentation (browning) and hypo-pigmentation (lightening) have also been noted after treatment.
        These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Avoiding
        sun exposure before and after the treatment reduces the risk of color change. _____ (initial)

    3. Infection:     Although infection following treatment is unusual, bacterial, fungal and viral infections
        may occur. Laser light can reactivate a latent stage herpes simplex virus around the mouth following a
        treatment, even in a person with no known history of herpes simplex virus symptoms. Should any type
        of skin infection occur, additional treatment or antibiotics may be needed. If you have a history of
        herpes simplex virus in the treated area we recommend preventive therapy. _____(initial)

    4. Bleeding:     Pinpoint bleeding is rare but can occur following treatment procedures. _____(initial)

    5. Allergic Reactions: Laser light may trigger an allergic reaction in persons with a history of allergies.
        _____(initial)

    6. I understand that exposure of my eyes to laser light could harm my vision. I must keep the eye
       protection goggles on at all times. _____(initial)

    7. If you currently have or had at one time, a tattoo in the area being treated, you must inform your
       technician prior to service. Not doing so may result in burns, blisters, discoloration and/or fading of the
       tattoo and/or skin. _____(initial)

    8. Itching caused by exfoliation of dead hair cells may occur. Additional treatment for the itching may be
       needed. _____(initial)

    9. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-
       pigmentation. _____(initial)

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled.
We will make every effort to notify you prior to your arrival. Please be understanding if we cause you any
inconvenience.

Acknowledgement:
My questions regarding this procedure have been answered satisfactorily. I understand the procedure and
accept the risks. I hereby release the certified laser specialist, Althea Medspa and its staff from all liabilities
associated with the above indicated procedure.

Client/Guardian Signature ________________________________                  Date_____________________

								
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