Bloom Health | History Form

We're excited for you to begin your Laser Hair Removal journey at Bloom Health. Have you received Laser Hair Removal in the past?

No, I'm a newbie — this is my first time! Yes, I've done this before

Which areas of the body would you like to treat with Laser Hair Removal?

*Women's Full Body includes Upper Legs, Lower Legs, Under Arm, Arms, Brazilian. Men's Full Body includes Chest, Upper Back, Lower Back, Abdomen, Neck Line. (Substitutions permitted, ask for details.)

Laser Hair Removal is customized according to your skin type, hair color, and hair thickness. Which skin type best describes you?

It's best to plan Laser Hair Removal around any active skin conditions or medical problems. Which of the following apply, if any?

Have you previously had Laser Hair Removal in the areas to be treated?

Are you tan in the areas to be treated (from sun exposure, tanning bed, or spray on)?

Have you had waxing or tweezing within the past 4 weeks in the areas to be treated?

Do you have any tatoos or permanent makeup in the areas to be treated?

Laser Hair Removal requires the treatment area to be shaved 12-24 hours in advance. Have you shaved the treatment area in advance?

Have you ever had an allergic reaction to any of the following?

Do you take any supplements or medications that thin the blood?

Are you pregnant or trying to become pregant?

Are you nursing?

We'd like to learn more about your skincare preferences. Which types of skincare products do you use in your usual skincare routine?

Have you used any of the following types of corrective skincare products in the past?

Do you prefer any specific medical grade skincare?

Do you consent to photos being taken in order to monitor the results and progress of your treatment?

Do you give permission to Bloom Health to use your photos publicly for educational or promotional purposes?

How'd you hear about us?

Almost done! Which type of music do you prefer during your Laser Hair Removal session?

HIPAA PRIVACY NOTICE

Bloom Health maintains compliance with the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides certain rights and protections to you as the patient, including protection of your Personal Health Information (PHI). HIPAA sets forth rules and restrictions on who has access to your PHI. If you'd like to view our HIPAA policy in its entirety, please click here.

GENERAL CONSENT TO TREATMENT

By entering my initials below, I verify that I have read and fully understand this questionnaire. I have responded to the questions truthfully. I understand that withholding information or providing misinformation may result in unforeseen side effects or complications. I am aware that it is my responsibility to inform Bloom Health and my treating provider of any updates to my health history. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I understand that not all treatments will have the same result for every client, therefore no guarantee can be given. The treatments I receive from Bloom Health are voluntary and I release Bloom Health, PLLC from liability and assume full responsibility thereof.

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