Laser Hair Treatment Form

The patient receiving services from The Body Studio, LLC (or the Guardian of the patient) must complete the following information before the first treatment session.

Patient Name

First NameLast Name

Date of Birth

For Patient

Date of Birth

For Patient

Mobile Number

Area CodePhone Number

We may send you special deals from time to time by text message which you will be able to opt-out of at anytime.

Other Number (optional)

Area CodePhone Number

Physical Address

Street Address

CityState / Province

Postal / Zip Code

Email

We may send you special deals from time to time by e-mail which you will be able to opt-out of at anytime.

How did you hear about us?

Who referred you?

If other, please specify:

Do you have a coupon? If so, please enter the coupon code or description:

Text body2019 to 555-888 for Exclusive Coupons

CONSIDERING OTHER SERVICES?

What areas have you considered treatment for today or in the future?

Are you currently being treated with hormone medication?

If yes, indicate the specific hormone medication and date of last use:

Leave blank if you answered NO to the last question.

Are you taking any medication that can cause sun sensitivity? (For example, certain antibiotics, Tetracycline, Tretinoin, Retin-A or Accutane)

If yes, indicate the medication you're taking for sun sensitivity and date of last use:

Leave blank if you answered NO to the last question.

Have you had any cosmetic fillers to the area(s) to be treated within the last year?

Check YES or NO on the following questions:

Rows	YES	NO
Are you sensitive to soaps or lotions?
Have you had significant sun exposure in the last 4 weeks?
Have you used sun beds or self-tanning products in the last 4 weeks?
Do you have tattoos or permanent makeup in areas to be treated?
Have you waxed the areas to be treated within the 4 weeks?
Are you currently pregnant or trying to conceive?
Have you used oral Isotretinoin within the last 6 months?
Does your skin get blotchy, red or irritated easily?

Have you ever experienced or been treated or the following?

Rows	YES	NO
Skin Cancer
Poly-cystic Ovaries
Cold Sores
Birth Control Pills
Hemophilia
Diabetes
Epilepsy/Seizures
Thyroid Disease
Keloid Disorder
Menopause

What you need to know for a Successful Laser Hair Removal Experience (check each box):

Check each box to indicate you have been made aware of each of the following:

Rows
Laser treatments may not produce permanent results. Due to the nature of the laser treatment an exact result can't be predicted. You acknowledge that no guarantees can be made on the results from laser treatment.
Possible side effects could occur such as skin discomfort, swelling, blistering or color changes.
We advise that any skin pigmentation procedures offered by The Body Studio, LLC should be discussed with a doctor prior to commencing treatment.
Color changes such as hyper-pigmentation or hypo-pigmentation may occur in laser treated skin.
Skin must be protected from the sun for several weeks before and after the treatment to help avoid possible side effects.
Although rare (less than 1%), the possibility of scarring may occur.
Cold sores may become active due to high light exposure in those prone to them.
You must wear proper eye protection recommended by cosmetic laser manufacturers during every procedure.

Cancellation Policy:

If you're unable to make your next appointment, The Body Studio requires that you inform them a minimum of 24 hours before the appointment by either text message or phone call to the office number (417) 771-8585. After two no shows, prepayment for your next appointment will be required.

I authorize the staff and members of The Body Studio, LLC to perform the following laser treatment procedures: Hair removal, skin rejuvenation, fat redcution, pigmentation reduction, veins/rosacea treatments, tattoo/scar removal treatments, acne/acne scar treatments and/or red blood vessel reduction, laser teeth whitening and massage.

I understand that multiple treatment sessions may be necessary to achieve satisfactory results and that the results can vary according to skin type, hair type as well as your medical condition.

I agree to allow The Body Studio, LLC to use photographs of the treated areas for documenting and monitoring of the treatment progress only.

By signing this form (The Body Studio, LLC Consent for Treatment) you and anyone claiming on your behalf can not hold The Body Studio, LLC, its affiliates, successors and assigns, officers, employees, representatives, partners and agents liable for past injuries, future injuries or damages of any kind.

Patient Name:

First NameLast Name

Guardian Name (if applicable):

First NameLast Name

Date you completed this form:

Date

Date you completed this form:

Date

Patient or Guardian Signature (use your finger or iPen)

If you’re the legal guardian of the patient receiving services from The Body Studio, LLC, you’re agreeing in its entirety to The Body Studio, LLC Consent for Treatment form on the patients behalf.

The Body Studio, LLC Treatment Form

The Body Studio, LLC Consent for Treatment