LaserLite Solutions | SimplePractice

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Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

Reason for care

What is the primary reason you are seeking care?

Which type of service are you requesting?

Consultation Only Laser Treatment Photobiomodulation (PBM) Therapy Not Sure — I would like guidance

Were you referred by a healthcare provider? (If yes, please provide the provider or clinic name)

Which area are you seeking treatment for?

Face Beard or jawline Scalp Neck Upper body Lower body Multiple area Airway or snoring therapy

How would you describe your skin tone?

Very light Light Light to medium Medium Medium to deep Deep

Do any of the following currently apply to you?

Recent laser, IPL, or energy–based treatment in the same area Recent chemical peel, microneedling or resurfacing treatment Recent tanning, sunburn or prolonged sun exposure Isotretinoin (Accutane) use within the past 6 months Active infection, open wound, cold sore, or rash in the treatment area New or recently changed prescription medications Pregnancy or breastfeeding History of keloid or abnormal scarring None of the above

Are you seeking same-day treatment if clinically appropriate?

Yes No, consultation only

Acknowledgement

I understand that not all individuals are candidates for same-day treatment. Treatment decisions are based on clinical assessment and safety considerations determined by the practitioner

Yes, I understand

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.