Kim Laudati Skin Care: Esthetic Intake Form Name:________________________________________________________________________________ Address:__________________________________ City: __________________ State: ____ Zip: _______ Email Address: (We only email a newsletter that includes a Member Discount one time per month!) _____________________________________________________________________________________ Phone:_______________________________________________ Date of Birth:____________________ Emergency Contact:_____________________________________ How did you hear about KLSC?____________________________________________________________ Skincare History Are you currently having skin treatments? Yes No *If yes, what type?_____________________________ Please circle if you are presently experiencing or have experienced in the past: Skin Cancer, Broken Capillaries, Dermatitis Treatment, Reactions, Keloid Scarring, Hypopigmentation, Acne, Hyperpigmentation, Rosacea Please circle if you have or have you had any of the following and include approximate month/year: Facial Cosmetic Surgery: Chemical Exfoliation (Peels): Collagen Injections: Cosmetics Fillers: IPL: Removal: Laser Resurfacing: Microdermabrasion:

Botox: Waxing: Other:

Laser Hair

Home Care Please circle the skincare products are you currently using at home: Cleanser, Vitamin C, Toner, Exfoliants/Scrubs/Machine Exfoliation, Moisturizer, Specialty Products and/or Serums, Eye Treatment Cream or Gel, Mask, SPF (Sun Protection) Please circle if you are using or have used any of the following: Benzoyl Peroxide (BP), Glycolic Acid (AHA,) Lactic Acid (AHA), Resorcinol, Salicylic Acid (BHA),Sulfur, Vitamin C ,Vitamin A/Retin A, Retinol, Hydrocortisone (HC), Hydroquinone (HQ) Please circle if you have been prescribed the following products:Tretinoin (Retin A, Retin-A Micro , Renova, Avita), Adepalene (Differin ), Azelaic Acid (Azelex , Finacea TM), Tazarotene (Tazorac ), Isotretinoin (Accutane), Triluma, Metrogel, Other Sun Protection Do you use a sunscreen? Yes No

What level of protection? (SPF #)

Have you tanned in a tanning booth or had any prolonged sun exposure in the last 14 days? Yes No

When exposed to the sun do you (Please circle one) Always burn, never tan. Always burn, sometimes tan. Sometimes burn, sometimes tan. Always tan. What skin conditions do you want to improve? (Please circle all that apply) Acne and/or breakouts, Rosacea Facial, Scarring, Uneven Tone, Hyperpigmentation (freckles, age spots),Enlarged Pores, Dehydration, Uneven, Texure, Oily, Surface Dryness, Hypopigmentation, Fine Lines and Wrinkles, Sun Damage, Other Health History: Please list any other known allergies:_______________________________________________________ Have you or are you being treated for any of the following? (Please circle all that apply) Cancer (what type)________________________, Hearing Aids, Pacemaker, High blood pressure, Thyroid condition, Diabetes, Heart problems, Arthritis, Asthma, Epilepsy, Seizure disorder, Hepatitis, Immune Disorder, HIV/AIDS, Lupus, Phlebitis, Blood Clots, Poor Circulation, Keloid scarring, Skin disease/skin lesions, Hormone Replacement Please list any medications you regularly take:_______________________________________________ Female clients only Are you pregnant or trying to become pregnant? Yes No Are you presently taking birth control pills? Yes No Photography Consent I herby grant permission to KLSC to take pictures of my body/face in the area of treatment strictly for my own personal “before” and “after” files. I understand that, in the event that KLSC shall wish to use these photos for commercial, educational or any other reason, they must obtain further permission directly from me. (Initial) ______________ Client Waiver I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I also understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. I hereby release Kim Laudati Skin Care from any liability pertaining to treatments, understanding that results cannot be guaranteed due to individual skin type(s) and condition(s). Client Signature: _____________________________________________________ Date: ____________

INTENSE PULSED LIGHT ACNE TREATMENT CONSENT FORM 1. I understand my acne treatments are performed with the Quadra Q4 Platinum Series which uses high intensity pulsed light. I understand the procedure may cause discomfort during treatment and a slight redness and irritation will occur on the skin after treatment. This irritation and redness usually subsides in 12 to 24 hours. In some rare cases side effects may include, but are not limited to, lightening or darkening of the skin, blistering, and/or skin irregularity. 2. I understand that acne treatment results vary from patient to patient. I also understand that in order for the acne treatment procedures to be effective, the following guidelines must be followed: a. Multiple consecutive treatments are performed until the desired result is observed. avoidance of active acne treatments and washes (Accutane, Retin-A, and other


b.T he

Photosensitizing Agents). 3. I understand that sun exposure 2 weeks prior to treatment and/or 2 weeks after treatment can possibly cause darkening or lightening side effects of the skin. 4. I understand that other forms of acne treatment methods exist. 5. All my questions regarding this procedure have been answered. 6. All my questions regarding this procedure have been answered. 11. I understand that the treating esthetician may take pre and post treatment pictures 12. I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I also understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. I hereby release Kim Laudati Skin Care from any liability pertaining to treatments, understanding that results cannot be guaranteed due to individual skin type(s) and condition(s). Common Drugs that cause photosensitive reactions: Please check off all that you have taken within the last 3 weeks and also those that you are currently still taking: Antibiotics: • • • • •

Dioxycycline (Vibramycin, Vibratabs) Demeclocycline (Declomycin) Tetracycline (Achromycin and others) Nalidixic Acid (NegGram) Lomefloxacin (Maxaquin)

Blood Pressure and Heart Medications: • • • •

Hydrochlorothiazide (Hydrodiuril, Oretic etc – may contain HCTZ) Chlorothiazide (Diuril and others) Furosemide (Lasix) Amiodarone (Cordarone)

Other Drugs: • • • • • • • • • • • • • • • • • • • • • • • •

• • • • • • • •

Chorpromazine (Thorazine) Methoxypsoralin PABA and or PABA esters (in chemical sunscreens) Alprazolam (Xanax) Amitriptyline Benzocaine (Sensorcaine and other numbing products) Captopril (Capoten) Chloradiazepoxide (Librium) Chloroquine Chlortetracycline Ciprofloxacin (Cipro) Co-trimoxazole (Bactrim, Septra) Dapsone Diltiazem (Cardizem and other names) Diphenhydraime (Benadryl, Benylin and other names) Enoxacin (Penetrex) Oestrogens (Birth Control Pills, Premarin and more) Fluoracil (5-FU) Glyburide (Diabeta, Micronase, Glynase and others) Griseofulvin (GrisPeg, Fulvicin, and others) Haloperidol (Haldol) Hydralazine (Apresoline) Ibupofen (Advil, Motrin, and more) Isoniazid (INH) Isotretinoin (Accutane) * Must have discontinued Accutane for a minimum of 6 months prior to treatment Methotrexate Minoxidil (Loniten, Rogaine) Naproxen (Naprosen, Alleve and others) Nifedipine (Procardia, Adalat) Norfloxacin (Noroxin) Nortiphtyline (Aventyl, and others) Ofloxacin (Floxin) Oral Contraceptives Oxytertracycline (Terramycin) Perfenazine (Trilafon)

• • • • • • • • • • • • • • • •

Phenylbutazone Phenytoin (Dilantin) Piroxicam (Feldene) Prochlorperazine (Phenergan) Protriptyline (Vivactil) Quindine (Quinidex, Quinaglute, Cardioquin and others) Quinine (Quinamm) Sulfonamide antibiotics (Bactrim, Septra, Gantrisin, and others) Thiordiazine (Mellaril) Thiothixene (Navane) Tolbutamide (Tolinase) Tretinoin (Retin-A) Trifluroperazine (Stellazine) Vitamin A (Retin-A, micro Retin-A, retinols) Citris Oils (direct application to skin with Lemon, Orange and others) St. Johns Wort (one month or more of usage = no IPL treatment for 3 months)

Print name: _________________________________ Signature: __________________________________ Date_________________________ Treating Esthetician: ________________________________________ Date:________________________