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 for your visit?

Which type of service are you requesting?

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

Were you referred to LaserLite Solutions?

No Yes, by a physician Yes, by another healthcare professional Yes, by family or friends Yes, by another source

Which area are you seeking treatment for?

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

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 Started or changed prescription medications within the past 30 days Pregnancy or breastfeeding History of keloid or abnormal scarring None of the above

If clinically appropriate, would you like to receive treatment on the same day as your consultation?

Yes No

Acknowledgement

I understand that submitting this prescreener does not guarantee treatment. Candidacy and same-day treatment are determined following clinical assessment and safety screening 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.