Laser Hair Removal – Client Intake Form

This document serves as a general intake form to cover all procedures offered by (Coco Vogue). Please complete these documents to your best knowledge and as thoroughly as possible. This will help us to be able to work out the optimal treatment plan for you. Separate Indemnity, Disclosure and Consent documents as well as Medical Update forms could possibly need to be completed before each treatment.

CLIENT INFORMATION: :

IN CASE OF EMERGENCY :

Name of local friend or relative:

Relationship to client:

Are you currently experiencing any of the following active skin conditions:

Do you currently have, or have you ever had any of the following conditions?

Have you taken any of the below Medications or Supplements within the last 6 months:

Isotretinoin (including but not limited to Roaccutane / Accutane / Isotone and similar) Anti-Coagulants / Blood Thinners (Including but not limited to Warfarin, Aspirin or similar) Photosensitizers (including but not limited to Anti-Depressants / Anti-Anxieties / Antibiotics) Contraceptive Medication Fish Oils / Plant Oils / Omega 3s or 6s

List ANY drug, make up, skin or food allergies that you are aware of:

Are you pregnant?

Yes No

List ANY hormonal problems or imbalances that you are aware of:

Are you currently under the care of a physician OR dermatologist ?

Yes No

If yes, please explain:

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

Yes No

If yes, please explain:

Do you have sensitive skin?

Yes No

If yes, please explain:

Have you ever had laser hair removal?

Yes No

Have you used any of the following hair removal methods in the past six weeks?

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

Yes No

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

Yes No

If yes, please explain:

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?

Yes No

If yes, please explain:

I hereby give consent to be photographed for the purpose of records and as proof for before and after treatment:

Yes No

I also give consent to be anonymously photographed for marketing and/or publication:

Yes No

Digital Consent

Due to the POPIA Act 4 of 2013, your consent is required as your personal information will be kept in our personal database and can be used in our private capacity to collect, share (as we find appropriate), stored or deleted. We will do all we can to protect your information.

Initial Signature here

I have been informed about the procedure of Laser Hair Removal treatments, including the potential benefits and risks which may include, but not limited to, redness, swelling, bruising, blistering, scarring, changes in skin pigmentation, and infection. I understand that while Laser Hair Removal treatments are generally effective, there is no guarantee of specific results, and individual outcomes may vary. I consent to forgo an allergy test, and I confirm that I am physically and medically capable to proceed with the recommended treatment regimen by (Coco Vogue) which I willingly undertake. I have carefully read and comprehended this document and have provided accurate answers. By signing this document, I release and absolve (Coco Vogue ) and its staff from any liability in the event of injury, loss, or harm to me. I also pledge to adhere to the aftercare instructions given and promptly inform my technician in case of any adverse reactions.

Enjoy a 10% discount on your First purchase!