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New Client Intake

BUILD 10.08-F1

Fill this out before your appointment — contact info, medical history, and consent, all on file when you walk in.

Step 1 of 5 — Contact Info

First Name

Last Name

Birthday

Address

City

State

Zip

Phone Email Emergency Contact Name Emergency Contact Number How did you hear about us?

What areas are to be treated?

A few quick yes/no questions

Have you ever been on Accutane?

Hormonal problem you've been treated for?

Chemical peel or scars in treatment area?

Medications that make you sensitive to light?

Medications / herbal supplements / topical creams you use Any allergies?

How often do you remove your hair?

Current hair removal methods (tap all that apply)

When was your last treatment?

Medical history — a few more

Skin Type (provider will confirm)

The Fitzpatrick Scale

Not sure? Find the closest match above — your provider will confirm it at your visit.

Laser Hair Removal Consent

Photo Consent

I consent to clinical before/after photos being taken and stored in my file for treatment tracking.

How may Precise Laser contact you?

Choose only the messages you want. All choices are optional and start unchecked.

Text me about appointments, including reminders and schedule changes. Text me replies to questions I ask Precise Laser. Text me promotions, birthday offers, discounts, and gift certificate offers. Email me promotions, birthday offers, discounts, and gift certificate offers.

Consent is optional and does not affect treatment. Message and data rates may apply. You may withdraw text consent by replying STOP or contacting Precise Laser.

Age

Are you 18 or over? * Required

Sign & Submit

Type your name below as your signature.

Client Signature (type full name)

Thank you!

You're all set. We'll have this on file for your appointment.

Book Your Appointment

Contact

The Laser Hair Removal & Personalized Skin Care in Babylon

Location

626 Deer Park Ave
Babylon, NY 11702

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