Client Information & Medical History

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
Today Date
Minor's Name
Email
Minor's Date of Birth
Home Address
Phone Number

Which of the following best describes your skin type (Please Circle One Type Number)

Always burns, never tans

Always burns, sometimes tans

Sometimes burns, always tans

Rarely burns, always tans

Brown, moderately pigmented skin

Black skin

Medical History
Are you currently under the care of a physician?

Yes

For what:

Are you currently under the care of a dermatologist?

Yes

For what:

Do you have a history of erythema ab igne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?

Yes

Do you have any of the following medical conditions? (Please Check All That Apply)

Cancer

Diabetes

High blood pressure

Herpes

Arthritis

Frequent cold sores

OHIV/AIDS

OKeloid scarring

Skin disease/Skin lesions

Seizure disorder

Hepatitis

Hormone imbalance

Thyroid imbalance

Blood clotting abnormalities

Any active infection

None of the above

Do you have any other health problems or medical conditions?

Yes

Please list:

Have you ever had an allergic reaction to any of the following? (Please Check All That Apply)

Food

Latex Aspirin

lidocaine Hydrocortisone

Hydroquinone or skin bleaching agent

Others

None of the above

Medications:
What oral medications are you presently taking?

Birth control pills

Hormones

None

Others Please list

Are you on any mood altering or anti-depression medication?

Yes

Have you ever used Accutane?

Yes

When did you last use it?

What topical medications or creams are you currently using?

RetinA

Others

None

Are you using herbal supplements regularly?

Yes

Please list:

History
Have you ever had laser hair removal?

Yes

Have you used any of the following hair removal methods in the past six weeks? (Please Check All That Apply)

Shaving

Waxing

Electrolysis

Plucking

Tweezing

Stringing

Depilatories

Have you had any recent tanning or sun exposure that changed the color of your skin?

Yes

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

Yes

Do you form thick or raised scars from cuts or burns?

Yes

Do you have Hyper-pigmentation (darkening of the skin) or Hypo-pigmentation (lightening of the skin) or marks after physic trauma?

Yes

Please describe:

Are you Female?

Yes

Please you need to complete the following questionnaire.

Are you pregnant or trying to become pregnant?

Yes

Are you using contraception?

Yes

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 and/or Blink Lash Club Management of my current medical or health conditions and update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

Parent or Guardian Information

Parent or Guardian Signature

Clear

Laser Hair Removal Client Consent Form Waiver of Liability

The purpose of this procedure is to diminish or remove unwanted hair. The procedure requires more than one treatment and produce permanent hair removal or certain period of time. The total number of treatments will vary between individuals. On occasion there are patient 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.

I agree and authorize Blink Lash Club Inc. and my technician/technicians to apply laser hair removal to myself. On this and future laser hair removal treatments. By mark the checkbox and "Yes or No”, I am agree to the following statement below:

I acknowledge the following problems may occur with the treatment.

1. Scarring: This treatment can create a bruising and a moderate burn or blister, temporary irritation, redness or slight swelling depending on skin sensitivity. For an effective treatment, the power (joules) needs to be just below the blistering point which means skin will be red. There is a risk of scarring.

2. Hyper-pigmentation (browning) and Hypo-pigmentation (whitening) have been noted after treatment, especially with a darker complexion. This usually resolves within weeks, but it can take as long as 3-6 months in some cases. Permanent color change is a rare risk. If you have a lot of color in your skin, a skin lightening cream will be advised to reduce the melanin in your skin before the treatment. Avoiding sun exposure after the treatment is crucial to reduce the risk of color change.

3. Infection: Although infection following this 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 in the mouth area. Should any type of skin infection occur, additional treatment including antibiotics may be necessary. If you have a history of herpes simplex virus in the treated area we recommend

4. Bleeding: Pinpoint bleeding is rare but can occur following brown spot and spider vein treatment procedures. Should bleeding occur, additional treatment might be necessary.

5. Skin Tissue Pathology: Energy directed at skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible. Only clearly benign pigmented lesions can be treated. Check with your doctor for a clearance

6. 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. Allergic reactions may require additional treatment.

7. Wear sunscreen of SPF 25 or higher before and after treatment to protect your skin.

8. I understand I may need multiple treatments for the desired outcome.

9. I understand that exposure of my eyes to light could harm my vision. I will keep the eye protection on at all times.

10. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, hyper-pigmentation and hypo-pigmentation.

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

I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions because I don’t have such medical/ health issue which prevent for laser hair removal.

I consent to the use of my before, during and after laser procedure photographs and/or videos for education, promotion purposes and use for the Blink Lash Club Inc. Website and Social Media advertising and blog.
Yes or No (Please Circle)

Yes

I acknowledge that I have answered all questions truthfully and completely.

I acknowledge that my questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks.

I hereby release and waiver all persons/ employees and Management representing Blink Lash Club Inc. including corporation and my technician/ technicians and anyone affiliated there from all liability associated with this procedure any injuries and/or current or future conditions resulting from the Laser Hair Removal or products and any types of claims, demands, damages, actions and cause of action arise out of the performance of services.

This agreement will remain into our system for future procedure and I will inform and alert the staff If there are any future changes to my medical history or health issue.

I understand this agreement legal and binding.

I certify that I have read or have had read to me the contents of this form and fully understand all information in this agreement and have given an accurate account of the questions. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction. I acknowledge that I have reviewed and approved the materials given to me and I authorize Blink Lash Club Inc and my Technician/ Technicians to perform desired procedure. This agreement will remain in effect for this procedure and all future procedures by the certified professional. I am over 18 years of age and consent to the agreement and to the laser hair removal treatment/ procedure.

I certify that I completely understand and comply with the above as stated.

Parent or Guardian Information

Parent or Guardian Signature

Clear

321 Bleecker St, New York, NY 10014

www.blinklashclub.com

Parent or Guardian Information

Parent or Guardian Signature

Parent or Guardian Information

Parent or Guardian Signature

Clear 321 Bleecker St, New York, NY 10014 www.blinklashclub.com Submit

Clear

321 Bleecker St, New York, NY 10014

www.blinklashclub.com