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Date of consultation: _______________________

Location: _____________________________________________________________________

Phone #: ________________________

Name of person providing information: _____________________________________________

Name of affiliated doctor: ________________________________________________________

Specialty of doctor: _____________________________________________________________

Doctor has performed hair removal with the device to be used since: ___________

How many procedures doctor has personally performed: ______

Name of person who would perform treatment: _______________________________________

Education/training professional affiliations of person who would perform treatment:

How many years of experience with the device to be used: __________

How many clients treated with device to be used: __________

How many times have they treated the body area for which I'm seeking treatment: __________

How many clients with my skin tone and hair color? __________

What kind of pain can I expect?

What do you use for patients who find it uncomfortable?

Do you write prescriptions for EMLA or painkillers? __ Yes __ No

Brand of device: ______________________________________

Manufacturer: ________________________________________

Device type: __ Nd:YAG __ Ruby __ Flash lamp __ Alexandrite __ Diode

__ Other [specify] __________________________________________________

Do you own or lease the device? __ Own __ Lease

When did you get the device? ________________

Why do you use this one versus the other devices available?

What are the benefits for me versus the other devices available?

What is the best published clinical data using this device?

What sort of skin cooling do you use during treatment?

What side effects have you seen using this device and how long did they last (best/worst case)?

What percentage of clients have had those side effects?

Contact info of clients who are pleased with results

(especially with my same sex, skin tone, hair color, and area treated):

Client 1: _____________________________________________

Email: _____________________________________________

Phone: _____________________________________________

Client 2: _____________________________________________

Email: _____________________________________________

Phone: _____________________________________________

Client 3: _____________________________________________

Email: _____________________________________________

Phone: _____________________________________________

Contact info of any clients who have been done for over a year:

Client 1: _____________________________________________

Email: _____________________________________________

Phone: _____________________________________________

Client 2: _____________________________________________

Email: _____________________________________________

Phone: _____________________________________________

Is this device cleared by FDA for permanent hair reduction? __ Yes __ No

Is this device cleared by FDA for use on my Fitzpatrick skin type? __ Yes __ No

Can you guarantee that my treatment will result in permanent hair removal? __ Yes __ No

Can you guarantee that my treatment will result in permanent hair reduction? __ Yes __ No

Can you guarantee that my treatment will result in long-term hair removal? __ Yes __ No

If so, how do you define long-term hair removal?

Describe your pricing policy, including terms of your multiple treatment contract:

What percentage of your clients didn't respond to treatment or were dissatisfied? _____

What is your policy in the case of client dissatisfaction?

If I still have hairs after my contract is up, what is your policy?

If I have a change in skin tone from treatment, what is your policy?

For information provider's signature:

I affirm the information in the consultation is truthful and accurate.

I have reviewed the information on his form and affirm that they reflect this establishment's position.

______________________________________________________________________________

Signature -----------------------------------------------(Printed Name)---------------------------------Date

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