Client Information & Physical Assessment

1. In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential.
2. How did you hear about us?
3. May we leave a message on you voicemail?
4. Which of the following best describes your skin type? *
5. Have you ever had any facial surgery performed?
6. Have you had any of the following injectable procedures
7. Have you ever had a laser procedure? *
8. Have you had a chemical peel? *
9. Have you had sun exposure or tanning booth exposure in the last 2 weeks? *
10. Are you currently under the care of a physician? *
11. If yes to #10, name of Physician and please explain
12. Are you currently under the care of a Dermatologist? *
13. Have you ever had a reaction to a previous laser treatment, heat treatment or radiation therapy? *
14. Do you have any of the following medical conditions?
15. Please list any other medical conditions or health problems not listed, current or past that may influence the treatment response:
16. Do you presently have or have you had a history of any of the following conditions?
17. Do you have multiple severe allergies?
18. Are you currently using: Aspirin, NSAIDS, Motrin, Advil, Aleve, Coumadin, Lovenox
19. Please list type of medication and reaction you experience
20. Do you have any allergies to ANY medication?
21. Do you have an allergy to:
22. Please list type of reaction you experience
23. What oral medications (including over the counter and supplements) are you presently taking?
24. Are you using medications that make you sensitive to light?
25. Are you on immunosuppressive therapy?
26. Do you have a history of anaphylaxis?
27. Have you received gold therapy treatment? *
28. Have you taken or taking any class of RA drugs (disease-modifying anti-rheumatic drugs (DMARDs)? *
29. Have you ever used Accutane? *
30. If yes, when was it last used?
31. What topical medications or creams are you currently using? Retin-A, Hydroquinone Others (Please list):
*Unless advised by your physician, all topical creams that may have a Retin-A or sun-sensitive ingredients should be discontinued 2 weeks prior to treatments.
32. Do you form thick or raised scars from cuts or burns?
33. Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
For our female clients:
34. Are you pregnant/trying to become pregnant? *
35. Are you breastfeeding? *
36. Are you using contraception? *
Signature Required:
Please review and Sign each condition below:
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, doctor or nurse of my current medical or health conditions and to update this history at each treatment.  A current medical history is essential for the caregiver to execute appropriate treatment procedures.

If you have COMMERCIAL INSURANCE, MEDICARE, HMO'S or MANAGED CARE : Maine Laser Clinic is not a contracted provider of any insurances, therefore payment is the full responsibility of the patient.