New Patient Consultation Form
Section 1: Personal Information
Date of Birth: Age:
City: , State: , Zip:
How were you reffered to us? (If Groupon, please list your 8 digit bar code number)
* Groupon/In-House Groupon Clients: Appointment required, subject to availability. Limited Saturday availability. A service fee of 18% on the full value of the service is required at the time of check in. Credit card needed to hold appointment. Cancellation fee of 25% of value of service. Not valid on federal holiday weekends. Black out days: 9/7, 10/9-10/12, 11/25-11/29, 12/23/-1/02, 1/15-1/18, 2/11-2/15.
Section 2: Skin Care Information
Are there any specific skin care concerns that you have today?
What is your skincare routine? Please include product names and regiment.
What do you like about your skin?
What do you not like about your skin?
Have you had Botox, injectables or any other invasive laser or surgery procedures recently or within the past 6 weeks? Yes No
Do you have any large pores or scars you would like to reduce or minimize? Yes No
Are you interested in skin tightening or collagen treatments? Yes No
Are you interested in an alternative treatment to Botox and injectable plumping fillers? Yes No
Are you interested in fat reduction and contouring? Yes No
Do you regularly sun bathe or go to tanning salons? How often?
When was your last sunburn?
Approximately how much water do you drink daily?
How often do you exercise? Please describe:
Have you ever had laser hair removal? Yes No
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 Hyper-pigmentation (darkening of the skin) or Hypo-pigmentation (lightening of the skin) or marks after physical trauma?
Section 3: Medical History and Medications
Are you currently under the care of a physician? If yes, please describe:
Are you currently under the care of a dermatologist? Yes No If yes, please describe:
Please list any oral medications that you are taking:
What antibiotics do you use to treat infections?
Are you currently taking any medications for heart conditions? If Yes, please list:
Do you have any allergies? Yes No If Yes, please list:
Are you currently taking any mood altering or anti-depressant medication? Yes No
Which topical medications or creams are you currently using?
Have you ever used Accutane (or similar medication)? Yes No
If Yes, when was your last use?
Have you had a cold sore within the last 6 months? Yes No
Do you have any major health conditions or auto immune disorders, skin disorders or diseases? Yes No
Do you have a history of Erythema Ab igne (EAI), 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 describe:
Please list any vitamins, supplements or supplemental herbs you may be taking:
(Female Patients Only)
Are you pregnant or trying to become pregnant?
Are you breastfeeding?
Are you using contraception?
If yes, which method?
Section 4: Consent
Please note that your consent to the questions below is for all current and future services/treatments at Blue Divine Aesthetics.
Please initial each statement after you have read it.
I understand that there are no guarantees with laser hair removal. I understand that laser does not work on grey or white hair. I understand that it may take up to 12 treatments before I get 85% reduction. If after 8 treatments I have absolutely no reduction then I understand that I am likely not a candidate. I understand that I will not be reimbursed for treatments that I have gotten.
I understand that I will need betwen 6 and 12 treatments to get 85% reduction. I understand that hormonal changes can bring back unwanted hair. I understand that it may take up to 5 or 6 treatments before I see hair reduction. I understand that the hair doesn't visibly burn up, disintegrate and fall out of the follicle. I understand that the results are gradual and subtle.
I understand that if I fail to come during my hair growth cycle, I will not get a reduction in the hair.
I understand that stubble will reduce my results. I understand that I am expected to come shaven. I understand that I will be changed $50 if the technician has to shave me.
I understand there is a 24-hour cancellation policy. I understand that I will be charged a fee to redeem the missed appointment.
I understand that packages cannot be broken up.
I understand that the laser can burn and fade my tattoos even if the light doesn't actually touch them. I also understand that Blue Divine is not responsbile for faded tattos.
I understand that I cannot tan or have on self-tanner when I come in for my laser appointment. I understand that I could burn and/or hyper pigment.
I understand that I cannot take medications (for example antibiotics) that may make me burn and be treated by the laser. I understand that if I start any new medications I must tell the technician before getting my treatment.
I understand that I will not be treated the day of my scheduled appointment if I have used topical tretinoin (retinoids) within 2 weeks of my scheduled appointment and there will be a 25% rescheduling fee.
I understand that lasers can cause burns, blisters, hypopigmentation, scars, skin swelling or itching. I agree to call the office within the first 24 hours of these symptoms for instruction on how to treat conditions.
I promise if I have any concerns or reactions I will notify the office immediately for Doctor Robert Colgrove, medical director, and MD to receive proper care and treatment, and allow proper post treatment care give by Blue Divine Aesthetics.
I understand that one of my appointments may be cancelled because of technical problems. We will re-book your appointment as quickly as possible. I understand that I will NOT always see the same tech. I understand that on occasion I may need to wait for my apointment as we accomodate other clients.
I understand that I will not be reimbursed or compensated for the previously mentioned predicament.
I understand that if I'm late for my appointment, my service time will have to be rescheduled or cut short.
I understand that other techs may enter the treatment room during my treatment.
I do not have any active cold sores.
I acknowledge that there is a rare possibility of an allergic reaction. I have previously used alphahydroxy acid products on my skin and/or in the past with no allergic reaction, but understand there still could be a response.
I agree to avoid direct sun exposure for 48 hours.
I agree to notify my esthetician of any concerns.
I agree not to wax for 72 hours pre/post treatment.
If I'm receiving laser hair removal services, there will be a $50 charge for patients who aren't shaved and need shaving. Your appointment may have to be rescheduled if you do not come shaved and our schedule does not allow enought time to perform your treatment.
We have a 48 hour cancellation policy. You will be charged full price for all appointments that are a no show and $50 for appointments that are cancelled in less than the 48 hour period. You must have a credit card on file at all times while receiving treatments at Blue Divine due to this cancellation policy. No refunds. Groupon clients will have a cancellation fee of 25% of value of service.
Section 5: Pre and Post Treatment Instructions
- Refrain from tweezing, bleaching or waxing the area(s) to be treated for a minimum of six (6) weeks prior to treatment. Alternative methods of hair management which are acceptable are shaving with a razor or electric clippers or trimming with manicure scissors.
- Avoid sun exposure, tanning beds and self-tanning creams that dye the skin for a minimum of three (3) weeks prior to treatment and throughout the course of treatments.
- If treating a facial area, refrain from using Retin-A, AHA's, and BHA's for 48 hours prior to treatment.
- Shave area to be treated prior to your appointment.
- If you get cold sores or genital herpes outbreaks, start taking Zovirax or a similar medicine before treatment.
- After treatment, you may have redness or bumps. This is normal. You may use a cold compress or aloe gel if needed.
- Avoid saunas, hot tubs, excessively hot baths and showers for 24 hours after treatment.
- Avoid sun exposure for a minimum of 24 hours after treatment AND for as long as the redness lasts in the treated area. REMEMBER! RED WILL BROWN IF EXPOSED TO THE SUN!!!
- If treating a facial area, refrain from using Retin-A, AHA's and BHA's for 48 hours after treatment to avoid irritation.
- If you experience itching in the area treated, apply 1% hydrocortisone cream and/or take an antihistamine such as Claritin or Benadryl.
- Make-up may be used.
- Use sun block SPF 30 or greater for a couple weeks after treatment.
- The only other acceptable hair removal methods during your treatment regimen is shaving or trimming as needed.
- Hair will shed up to three weeks after treatment. It may seem like new hair growth, but it is hair coming out. You can help the hairs come out by gently using a loofah or a washcloth.
I have read and understood the above pre and post treatment instructions and I agree to abide by them.
I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professional of my current medical or other health professional of my current medical or health conditions to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.