Medical Release Form

Confidential Client Medical History

Name:

DOB

Age:     Occupation:

Address

City State   Zip Code

Cell Phone Work   Work

Email:

May we text you appointment reminders?   Yes   No
If yes, please provide your telephone carrier name

How did you hear of us?

General Medical History

Accutane	Yes	No
Acne	Yes	No
Cancer	Yes	No
Cold Sores	Yes	No
Contact Lenses	Yes	No
Dermatitis/Eczema	Yes	No
Diabetes	Yes	No
Epilepsy	Yes	No
Genital Herpes	Yes	No
Heart Condition	Yes	No
High Blood Pressure	Yes	No
HIV Positive	Yes	No
Keloid Scars	Yes	No
Pacemaker	Yes	No
Rosacea	Yes	No
STD's	Yes	No

Have you had a negative reaction to chemical peels? Yes No

Existing Skin Conditions (Check all that apply)

Pigmentation	Rash	Permanent Makeup
Red Spots	Body Piercing(s)	Tattoos
Hair in the wrong place	Spider Veins

What skin care line(s) do you use?

Allergies (Check all that apply)

Latex	Hydrocortisone
Aspirin	Salicylic Acid
Hydroquinone or skin bleaching agents	Onion Extract
Lidocaine

Please list any other allergies below:

Medical and Dietary Supplements

What oral medications are you presently taking?

Do you regularly take Baby Aspirin, Coumadin or other Blood Thinners?   Yes   No

What topical medications or creams are you currently using?

Are you on photosensitizing medications such as Tetracycline or Retin-A?   Yes   No

Do you take fish or flax oil supplements?   Yes   No

Ginkgo?    Yes   No

What other dietary supplements do you take regularly?

Female Clients Only

Are you pregnant or trying to become?    Yes   No

Are you breast feeding?    Yes   No

Are you using hormonal contraception?  Yes   No

When is your next period

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, doctor or nurse of my current medical or health conditions and to update this history. I understand there are no refunds offered on unwanted treatments and no returns are given for treatments with unsatisfactory results.
Signature:

Skin Typing Worksheet

What is your eye color?	Light blue or gray	Blue or green	Hazel or Light brown	Dark brown	Brownish black
What is your eye color?
What is your natural hair color?	Red, sandy red	Blonde	Dark blonde chesnut,brown	Dark brown	Black
What is your natural hair color?
What is the color of your skin (unexposed reas)?	Reddish	Very pale	Pale with beige tint	Light brown	Dark brown
What is the color of your skin (unexposed reas)?
Do you have freckles on exposed areas?	Many	Several	Few	Incidental	None
Do you have freckles on exposed areas?
What happens when you stay in the sun too long?	Painful, redness blistering and peeling	Blistering followed by peeling	Burns,sometimes followed by peeling	Rarely burn	Never burn

To what degree do ou turn brown?	Hardly any or not at all	Light tan	Resonable tan	Tan very easily	Turn dark brown easily
To what degree do ou turn brown?
How does your face responed to the sun?	Very sensitive	Sensitive	Normal	Very resistent	Never has problems in sun
How does your face responed to the sun?
When did you last expose yourself to the sun, tanning bed or self tanning creams?	More than 3 months ago	2-3 months ago	1-2 months ago	Less than 1 month ago	Less than 2 weeks ago

How often is the area that you want to have treated exposed to the sun	Never	Hardly ever	Sometimes	Often	Always

Skin Score (Total Number)

Skin Score	Skin Type
0 - 7	I
8 - 16	II
17 - 25	III
26 - 30	IV
Over 30	V - VI

Client Consent for Laser Hair Reduction

Patient Name:

Procedures: Laser Hair Reduction
Lasers: Quanta Alexandrite 755nm
Quanta Nd:YAG 1064nm

I hereby authorize and direct any associates or employees of Vasu, Inc to perform laser hair reduction on me. These treatments are only effective on actively growing hair. Multiple treatments are required to achieve cosmetically acceptable results. White, grey, red and blond hair will not respond to laser treatments. In rare cases, patients may not experience any hair reduction even with multiple laser treatments. I specifically acknowledge that no guarantees or warranties have been made concerning the results of the procedure.

The following points have been discussed with me and I understand: (please initial each statement)

The potential benefits of laser hair reduction.*

The most likely possible complications or risks involved with laser hair reduction include but are not limited to burns, blistering with infection and scaring, scabbing, herpes simplex virus activation, itching, red-purple discoloration, bruising and long-term pigmentary changes. Hypo-pigmentation or hyper-pigmentation could be permanent.
*

Blistering, infection, scarring, scabbing, bruising and long term pigmentary changes are more likely in people that are not honest about their tanning habits or who try to tan during their treatments. Tanned skin cannot be treated with the Alexandrite 755nm laser. I understand that it is my responsibility to let my technician know if I have received any tan throughout the course of my treatment.*

The presence of medical conditions that alter the hormone balance in females may limit the effectiveness of laser hair reduction.*

Close adherence to ideal laser schedules will improve your results. Conversely, failure to follow the laser schedule may diminish your results and in turn require more treatments than normal.*

Laser treatments tend to synchronize the growth cycle of hair; therefore, there may be the perception of increased hair growth during your treatments. This usually occurs near the third or fourth treatment. This is an ideal time to perform laser hair reduction due to the increased percentage of actively growing hairs that are the ideal targets for laser treatments.*

Topical anesthetic is not usually necessary as this laser uses a Zimmer Cryo 6 cooling device to reduce discomfort when the laser pulse is delivered. Topical anesthetic creams will reduce the discomfort in sensitive areas.
*

Eye protection must be worn at all times during the treatment.*

I hereby authorize Vasu, Inc or any associates to take pictures of the treated area to be used in my patient file and/or teaching purposes. I understand that the release of this information will be kept confidential and that no patient names will be used.*

I am not pregnant (female patients) and shall notify Vasu, Inc, if that changes.*

I have been given the opportunity to ask questions about the procedure(s). My questions have been answered and I understand the information given to me.*

Contraindications to the performance of this procedure(s) have been discussed in detail with me and I understand that my skin’s condition may actually temporarily worsen as a result of this treatment.*

I recognize that the practice of laser medicine is not an exact science and acknowledge that no guarantees have been made to me concerning the results of such procedures and thus no monetary refunds will be issued to me on any previous or future treatments.*

I understand that immediately following the laser treatment, the treated area will appear as a red discoloration and have edema (swelling). The redness (erythema) and discoloration may take up to 6 months to heal. The treated area will feel like a sunburn for a few hours after treatment.*

I received the after care instructions for laser hair reduction.*

I understand that I shall not spray tan, use self tanning lotions and sun tan during my treatments. The sun and tanning lotions are a competing chromophore for the laser.*

I understand and agree to give at least 24-hour cancellation or re-scheduling notice and I agree to pay a minimum of $50.00 or forfeit my treatment if I don’t give proper notification.appointments.*

ACKNOWLEDGEMENT

I understand that I release Vasu, Inc and its associates, the Medical Director, the laser technician performing the procedures and any other person involved in my treatment from any liability associated with complications from the laser procedure. By my signature below, I certify that I have read and fully understand the contents of this permission and authorize the performance of laser hair reduction by the staff of Vasu, Inc.

Signature:

(PURSUANT TO 45 CFR 164.508)

“This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.”

Vasu Skin Solutions is dedicated to protecting the private and medical information of our patients.

It is our firm policy not to share any client information without written permission from the client. Below is a brief summary of our policy and disclosure permission form. If you already have someone in mind that might need access to your medical records, please list that person below.

Vasu’s, policy was put in place to protect your “protected health information” or “PHI”. Therefore we will not discuss any information with you, or anyone else, without first verifying your identity by date of birth, address and getting your written permission to do so.

Your PHI will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers if desired, laboratories and health insurance payers as it necessary and appropriate for your care. Your signature below indicates that you understand and accept Vasu, Inc’s privacy policies. The full description go our privacy policies are located here: www.vasuskinsolutions.com/about-vasu/policies

Release of Information (Check the appropriate boxes and complete the requested information)

* I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:

Spouse:

Parent:

Other:

Information is not to be released to anyone except self.

This Release of Information will remain in effect until terminated by me in writing.

Messages:

Please call my home my work my cell number:

If unable to reach me:

you may leave a detailed message

please leave a message asking me to return your call

By signing, I acknowledge that I have read, understand, and agree to Vasu Skin Solutions’ Privacy Policy.

Name of Adult Participant and/or Parent or Legal Guardian of Minor:

First Name:	Last Name:	Birth Date:
Address:	City:	State:
Zip:	Email:	Phone:

Relationship to minor:

Full Name and Birth Date of family members under the age of 18

#1	First Name:	Last Name:	Birth Date:
#2	First Name:	Last Name:	Birth Date:
#3	First Name:	Last Name:	Birth Date:
#4	First Name:	Last Name:	Birth Date:
#5	First Name:	Last Name:	Birth Date:
#6	First Name:	Last Name:	Birth Date:
#7	First Name:	Last Name:	Birth Date:
#8	First Name:	Last Name:	Birth Date:
#9	First Name:	Last Name:	Birth Date:
#10	First Name:	Last Name:	Birth Date:

Date and Time Signed:

By checking this box I agree to have read and agree to the legal agreement above.

Add to mailing list

Your browser is not supported. Please update your browser

Fill in Adult/Legal Guardian Info

Fill in Children Info

Full Name and Birth Date of family members under the age of 18

Your browser is not supported. Please update your browser

Laser Hair Removal Forms

Please fill out information about yourself.

Vasu Skin Solutions - Please Complete Information

Fill in Adult/Legal Guardian Info

Fill in Children Info

Please answer all questions, initial and sign where noted.

Name of Adult Participant and/or Parent or Legal Guardian of Minor:

Full Name and Birth Date of family members under the age of 18