CLIENT INFORMATION & MEDICAL HISTORY
Welcome to Nyah Med Spa! We are looking forward to your first visit. Every new client must book a free initial consultation prior to treatment. This will allow us to assess your skin/hair type and perform a test spot with the laser to make sure you do not have any adverse reaction. You will be able to start your treatments 48 hours after the test spot.
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.
PERSONAL HISTORY
Which of the following best describes your skin type?
I - Always burns, never tans
II - Always burns, sometimes tans
III - Sometimes burns, always tans
IV - Rarely burns, always tans
V - Brown, moderately pigmented skin
VI - Black skin
TREATMENT HISTORY
Have you ever had laser hair removal?*
Yes No
Have you used any of the following hair removal methods in the past six weeks?
Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories
Have you had any recent tanning or sun exposure that changed the color of your skin?*
Yes No
Have you recently used any self-tanning lotions or treatments?*
Yes No
Do you form thick or raised scars from cuts or burns?*
Yes No
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
Yes No
For our female clients:
Are you pregnant or trying to become pregnant?*
Yes No
Are you breastfeeding?*
Yes No
Are you using contraception?*
Yes No
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, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
Date:
Signature:
MEDICAL HISTORY
Are you currently under the care of a physician?*
Yes No
Are you currently under the care of a dermatologist?*
Yes No
Do you have any of the following medical conditions? (Please check all that apply)
Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?*
Yes No
Do you have any other health problems or medical conditions? Please list:
Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced)
Client Treatment Consent and Release
I acknowledge that beauty treatments, the practice of skin care, and the practice of massage, including, but not limited to, microablation, microdermabrasion, waxing, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vin treatments, brown spot removal, BOTOX, Collagen, Dermal Fillers, Sclerotherapy, Mesotherapy, Dermaplaning, and various other beauty procedures is not an exact science and no specific guarantees can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference.
I also understand and agree to assume the following risks and hazards which may occur in connection with any particular treatment including but not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, nerve damage, scarring, infection, change in skin pigmentation, allergic reaction, muscle damage, and increased hair growth. I understand that even tough precautions may be taken in my treatment, not all risks can be known in advance.
Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold harmless and release from any and all liability the company and the individual that provided my treatment, the insured, and any additional insureds, as well as any officers, directors, or employees of the above companies for any condition or result., known or unknown, that may arise as a consequence of any treatment that I receive.
I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties.
Date:
Signature:
SPA POLICIES
We respect your time and appreciate your choice to spend it with NYAH Med Spa. We've created our Spa Policies to provide the utmost versatility and convenience to our guests. Booking a reservation is your acceptance of our Spa Policies; therefore, please be certain you've reviewed and agreed to these terms.
Please respect our scheduling by keeping appointments whenever possible and providing a minimum of 24 hour notice when canceling or rescheduling appointments. Failure to comply with these guidelines will result in a loss of treatment or a fee of $25.
- Less than 24-hour notification to cancel or reschedule an appointment.
- No-show or missed appointments.
- Late arrivals - please keep in mind that arriving late for a service may require us to shorten the length of the treatment, with full charges applied, so as not to inconvenience other guests. We regret that late arrivals will not receive extension of scheduled appointments unless our schedule allows.
- We have a NO REFUND policy, however we will consider an exchange for other services.
- Vouchers are accepted from NEW CLIENTS ONLY; Vouchers from existing Clients will not be redeemed. We consistently offer extremely competitive in-house prices on our services and for this reason we can NOT extend any voucher exceptions to our existing clients.
Date:
Signature:
Laser Hair Removal Client Informed Consent Form
Welcome to Nyah Med Spa! We are looking forward to your first visit. Every new client must book a free initial consultation prior to treatment. This will allow us to assess your skin/hair type and perform a test spot with the laser to make sure you do not have any adverse reaction. You will be able to start your treatments 48 hours after the test spot.
Client Name:*
Treatment Sites:
Previous Hair Removal Methods:
The purpose of this procedure is to diminish or remove unwanted hair. The procedure requires more than one treatment and may produce permanent hair removal. The total number of treatments will vary between individuals. On occasion there are patients that do not respond to treatments. The treated hair should exfoliate or push out in approximately 2-3 weeks.
Alternative methods are waxing, shaving, electrolysis, and chemical epilation.
The following problems may occur with the hair removal system:
1. There is a risk of scarring.*
I understand
2. Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation (browning) and Hypopigmentation (lightening) have also been noted after treatment. These conditions usually resolve within 3-6 months, but permanent color 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.*
I understand
3. Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.*
I understand
4. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.*
I understand
5. Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. Systemic reactions (which are more serious) may result from prescription medicines.*
I understand
6. I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.*
I understand
7. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.*
I understand
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 to the office. Please be understanding if we cause you any inconvenience.
ACKNOWLEDGMENT:
My questions regarding the procedure have been answered satisfactorily. I nderstand the procedure and accept the risks. I hereby release (individual) and (facility) and (doctor) from all liabilities associated with the above indicated procedure.
Date:
Signature:
Post Treatment Instructions:
The purpose of this procedure is to diminish or remove unwanted hair. The procedure requires more than one treatment and may produce permanent hair removal. The total number of treatments will vary between individuals. On occasion there are patients that do not respond to treatments. The treated hair should exfoliate or push out approximately 2-3 weeks. Treatment duration varies from 15-120 minutes depending on the size of the area and the amount of hair.
1. Avoid the sun 2-4 weeks before and after treatment.
2. Hair must be shaved in the treatment area 12-24 hours prior to any hair removal procedure.
3. It is best that you refrain from tweezing, threading, and/or waxing 4 weeks prior to treatment. Shaving is the only method that can be done.
4. You MUST avoid bleaching, plucking or waxing hair for 6 weeks prior to
5. Avoid deep tanning, including tanning beds and tanning creams 2 weeks before and a 1 week after treatment. If you must go in the sun use a sunscreen of SPF 25 or higher.
6. If throughout the course of your treatment, you need to take any photosensitizing medication and/or antibiotics, we will not be able to treat you within 10 days of your last dose.
7. We ask that you arrive to your treatment with no lotions, sprays or creams in the treatment area.
8. A minimum of 6 weeks in between treatments is required to achieve maximum results, depending on the area.
Post Treatment Instructions:
1. Immediately after the treatments, there should be redness and bumps at the treatment area, which may last up to 2 hours or longer. It is normal for the treated area to feel like sunburn for a few hours. You should use a cold compress if needed. If any crusting, apply antibiotic cream. Some physicians recommend aloe vera gel or some other after sunburn treatment such as Desitin. Darker pigmented people may have more discomfort than lighter skin people and may require the aloe vera gel or an antibiotic ointment longer.*
I understand
2. Makeup may be used after the treatment, unless there is epidermal blistering. It is recommended to use new makeup to reduce the possibility of infection. Just make sure that you have moisturizer on under your makeup. In fact, moisturizer will help the dead hair exfoliate from the follicle, so use moisturizer frequently and freely on the treated area. Any moisturizer without alpha-hydroxy acids will work.*
I understand
3. Avoid sun exposure to reduce the chance of dark or light spots for 2 months. Use sunscreen SPF 25 or higher at all times throughout the treatment and for 1-2 months following.*
I understand
4. Avoid picking or scratching the treated skin. DO NOT USE any other hair removal methods or products on the treated area during the course of your laser treatments, as it will prevent you from achieving your best results.*
I understand
5. You may shower after the laser treatments, and use soap, deodorant, etc. The treated area may be washed gently with a mild soap. Skin should be patted dry and NOT rubbed. You may apply deodorant after 24 hours.*
I understand
6. Anywhere from 5-30 days after the treatment, shedding of the hair may occur and this may appear as new hair growth. This is not new hair growth, but dead hair pushing its way out of the follicle. You can help the hair exfoliate by washing or wiping with a washcloth.*
I understand
7. Hair re-growth occurs at different rates on different areas of the body. New hair growth will not occur for at least three weeks after treatment.*
I understand
8. Call your physician’s office with any questions or concerns you may have after the treatment.*
I understand
Please note: Stubbles, representing dead hair being shed from the hair follicle, will appear within 10-20 days from the treatment date. This is normal and will fall out quickly.
Date:
Signature:
Laser Hair Removal Treatment Questionnaire
Complete form and then allow your Laser Technician to read all answers and submit.
1. Have you been on any antibiotics and/or sun-sensitive medications in the past two weeks? This includes any medications that are a contraindication to laser treatments.*
Yes No
2. Have you had any long term sun exposure in the past 4 weeks?*
Yes No
3. Are you pregnant and/or breastfeeding?*
Yes No
4. Are you going to have any long term sun exposure in the upcoming weeks?*
Yes No
5. Have you used any sunless tanner in the past 2 weeks on the areas that we will be treating today? It is important that you do not have any sunless tanner residue on your skin; as this can lead to pigmentation issues.*
Yes No
6. Have you used any prescription creams on any areas of the body? Example: Retin A, Renova, Tretinoin, Avita, Alustra, Adapalene, Avage, Differin, Tazorac, Tazarotene, etc.*
Yes No
7. Have you waxed, tweezed, threaded, or used depilatories between treatments on any of the areas we will be treating today?*
Yes No
8. Do you have makeup and/or deodorant and/or lotions on any of the areas we will be treating today?*
Yes No
9. Do you have any of the following hair color(s) in the area(s) being treated? Gray, White, Blonde, Strawberry Blonde, Light Brown*
Yes No
10. Do you have any tattoos on the area(s) being treated? If the answer is yes, you take full responsibility for making the Technician aware of the tattoo(s)*
Yes No