Date of assessment:
Age group
Under 2020-3030-40
Contra-Indications
Pre-existing Condition(s) YES / NO Pre-existing Condition(s) YES / NO
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If yes to any of the above, give brief details here:
Is there doctor’s permission needed?
YesNo
Evidence attached
YesNo
Fitzpatrick Scale/Skin Type:
IIIIIIIVVVI
Have you been in the sun, in a hot climate or on a sunbed in the last 12 weeks
YesNo
Hair Removal Areas you want to consider treating
Density of hair:
CoarseFine
Hair Colour:
Dark pigmentMedium pigment
have you treated the hair previously?
YesNo
Method to be used today:
Laser OIPL