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Laser Consultation Form

Part I Contact Information

First Name

Last Name

phone

How do you prefer to be contacted?

Part II Your target areas and skin type

Please indicate the areas where you wish to have your treatment.

Please review the table below and indicate your Fitzpatrick skin type from the pull-down menu.

What color is your hair in the area you want to be treated?

Please indicate if you use tanning beds or have tanned recently. Yes
No

If you answered yes, when was the last time you tanned?

Part III Hair Removal History

Have you had laser treatment before? Yes
No

If yes, when was your last treatment?

How many treatments have you had?

If no, do you currently use any other methods of hair removal such as waxing, electrolysis, threading, bleaching or any others? Yes
No

If yes, what method do you use?

When was the last time you had a treatment?

Part IV Medical History

Do you have any skin allergies or skin sensitivities? Yes
No

If yes, what are they? Yes
No

Have you been on Accutane in the past 6 months? Yes
No

Are you currently on any medication? Yes
No

If yes, does it cause photosensitivity? Yes
No

What is the name of the medication?

Part V Additional Information

Please indicate if there is any additional information you'd like to share with us. Any information, questions, or concerns you provide will be discussed in confidence during your complimentary consultation.

Please indicate when you'd like to have your complimentary consultation with one of our certified laser technicians.

604.732.9901

Request an Appointment

Som Visao Spa

Hycroft Medical Building #8-3195 Granville St, Vancouver, BC V6H 3K2

Mon - Fri 9:00am to 9:00pm | Sat & Sun 10:00am to 6:00pm

Featured in HealthChoices.ca: Vancouver's Medical & Lifestyle Solutions Directory

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The Lipo Laser treatments are not only pain free and non invasive, they are relaxing and most importantly, they work!

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