Harlem Zen Client Consultation

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Image Field
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Date * This field is required.
Date
Year
Month
Day
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Name* This field is required.
First Name
Last Name
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Email Address* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Date of Birth
Date
Year
Month
Day
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Have you had any recent surgeries or serious health concerns?* This field is required.Lifestyle Assessment
YesNo
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If 'yes', please specify
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When, if ever was your last skincare treatment?Never
Date
Year
Month
Day
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What would you like to achieve from your treatment plan?* This field is required.To reduce the dark marks around the hairline
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Which (if any) of the following are areas of concern for you:* This field is required.Uneven skin tone
Dehydration
Wrinkles/Fine lines
Puffiness
Dark Circles
Cracked/chapped lips
Whiteheads
Blackheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness
Liver spots/age spots
Uneven skin tone
Sun damage
Ingrown hair/ Razor bumps
Dull/dry skin
Flaky skin
Melasma
Birthmark
Scar
Cystic acne
Keloids
Post acne pitting
Unwanted hair
Hyperpigmentation
Other
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Do you have any known allergies or sensitivities?
YESNO
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If yes, list allergies.
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Do you experience sensitivity to scents or specific smells?
YESNO
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If yes, please list.
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Have you ever had a chemical peel?No
YesNo
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Have you ever had Laser Hair Removal?* This field is required.No
YesNo
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Have you ever had Microdermabrasion?No
YesNo
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Do you use any of the following active treatments?* This field is required.Check all that apply.
Retin-A
Renova
Accutane
Adapalene Hydroxyl Acid
Retinol/Vitamin A derivative
None of these
Other
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Please list any other skincare treatments or medications you have used in the past two weeks
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If applicable, when did you last use Retin-A, Renova, Accutane, Adapalene Hydroxyl Acid, or Retinol/Vitamin A derivative?
Date
Year
Month
Day
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Which of the following have you used for hair removal in the past six weeks?* This field is required.Check all that apply
Laser
Waxing
Electrolysis
Tweezing
Threading
Depilatories (Nair, etc)
Razor
Electric Shaver
Sugaring
None of These
Other
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Do you experience irritation from shaving?Yes
YesNo
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Are you pregnant, trying to become pregnant or lactating?* This field is required.No
YesNo
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Are you undergoing any hormonal treatment or hormone therapy?No
YesNo
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If yes, please provide details relevant to treatment.
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Do you suffer from diabetes or experience neuropathy?* This field is required.No
YesNo
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ACKNOWLEDGEMENT OF NO-SHOW/ LATE CANCELLATION POLICY* This field is required.Selecting "Yes" indicates you have read, understood and accepted the terms of the No-Show/ Late Cancellation Policy below. Harlem Zen strives to provide each client with the highest quality of care while attempting to accommodate your schedule. Your consistent attendance of the planned treatment regime is paramount to your results. To better service all clients we ask that you please reschedule or cancel 24 hours prior to the start of your appointment. Last minute cancellations, along with no-shows hinder our ability to accomodate the scheduling needs of other clients. Therefore we must ask for your full cooperation with the following policy: **If you are unable to keep a scheduled appointment, we request that you notify us no less than 24 hours in advance so that your appointment can be rescheduled, and enable us to open that slot for someone else in need. **A 25% Late cancellation charge will be added to your account if we do not receive 24 hours notice. **A 50% No-Show charge will be charged to your account if we do not receive any notice of your absence. We believe this policy is necessary for the benefit of our clients as a whole so that we may continue to provide quality services in a convenient way. We appreciate the opportunity to be a part of your skin care program. Thank you for your cooperation and consideration for our staff and other clients. I, [NAME] have given Harlem Zen permission to charge my account in accordance to the No Show/ Late Cancellation Policy as described above.
YESNO
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If you have any questions, list here.
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How did you hear about us? (if referred please list names)* This field is required.Google
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Please share the contact information of anyone who may appreciate a complimentary consultation with us. You get a 25 ZEN Points each time your referral books and completes a service!
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Informed Consent to Nd YAG Laser Treatment* This field is required.Selecting "Yes" indicates you have read, understood and accepted the terms of the Informed Consent below. I, [NAME] have given Harlem Zen permission to perform Nd:YAG laser procedures on my person. The LightPod Neo® (Nd:YAG 1064nm) laser is FDA approved for a variety of procedures including hair removal, vein treatment and wrinkle reduction. This form provides information you need to make an informed choice of whether or not to undergo Nd:YAG laser treatment. Although laser treatment is effective in most cases, no guarantee can be made that a specific patient will benefit from treatment. The laser emits an intense beam of light that is absorbed in specific body tissues within the skin, and depending upon the type of procedure, several treatments may be required at intervals specified by the physician. Some of possible complications of Nd:YAG laser treatment are: 1. Discomfort – The procedure is done so precisely that surrounding tissue is minimally affected; the patient may experience a mild sensation of pain in the treated areas. Some degree of skin flushing may occur, but it typically resolves within several hours. 2. Scarring – There is a small chance of scarring, including hypertrophic scars, or very rarely, keloid scars. To minimize chances of scarring, it is important that you follow all postoperative instructions carefully. It is important that any prior history of unfavorable healing be reported. 3. Pigmented changes – The treated area may heal with lighter or darker pigmentation. This occurs more often in darker pigmented skin and following exposure of the area to the sun. It is recommended that you protect yourself from any sun exposure for at least three months following treatment. Hyperpigmentation usually fades in three to six months. However, pigment change can be permanent. 4. HSV Reactivation – The patient agrees to notify the physician if he/she has any history of Herpes viral infections, as the laser procedure may cause it to reactivate. 5. Lack of Treatment Response – There is a possibility that the targeted hairs, veins or other treated areas will not respond to the treatment. This is often a function of the specific body chemistry of the patient, including relative pigmentation and light absorption characteristics of the patient’s various body tissues. 6. Photography - I agree to have photos taken of the area with the exception of genital areas to track the progress of the treatments. Photographs may be used for promotional purposes. 7. Eye Exposure – There is also the risk of harmful eye exposure to laser surgery. Safeguards should be provided by the laser practitioner. It is important that you keep your eyes closed and have protective eye wear at all times during the laser treatment. I certify that I have read or have had read to me, the content of this form. I understand the risks and alternatives involved in this procedure. I have had the opportunity to ask questions and all of my questions have been answered. I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure,and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
YESNO
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Thank You! This information will be used to ensure you receive the long lasting results you desire! If you haven't already, click the link and Book your appointment TODAY!!
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