Lam Probe Patient Application

General

FirstName:

LastName:

Date:

Age:

Address:

City:

State:

Zip Code:

Phone Home:

Phone Work:

Phone Cell:

Date of Birth:

Marital Status:

Employer:

Occupation:

Emergency Contact:

Relationship:

Emergency
Phone Home:

Emergency
Phone Work:

Emergency
Phone Cell:

Email Address:

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Health History

Medications:

(prescription and over the counter; vitamins, herbal medications)

Allergies:

Surgeries
/Dates:

Dental Implants:

Yes No

What Type?

Skin Conditions

Skin Tags:

Yes No

Fibromas:

Yes No

Angiomas:

Yes No

Other:

PMS:

Yes No

Period Acne:

Yes No

Are you?

Pregnant:

Yes No

Nursing:

Yes No

Do you?

Smoke:

Yes No

Drink Alcohol:

Yes No

Amount per day:

Skin Type

(1) Highly sensitive, always burns, never tans. Ex: Red hair with freckles
(2) Very sun sensitive, burns easily, tans minimally. Ex: Fair skinned, fair haired Caucasians
(3) Sun sensitive skin, sometimes burns, slowly tans to light brown. Ex: Darker Caucasians
(4) Minimally sun sensitive burns minimally, always tans to moderate brown. Ex: Mediterranean type Caucasians.
(5) Sun insensitive skin, rarely burns, tans well. Ex: Some Hispanics and blacks.
(6) Sun insensitive skin, never burns, deeply pigmented. Ex: Darker Blacks.

Home Care Advice

After treatment with the Lam Probe, the areas treated may feel:

Irritated as well as redness and scabbing may form.
Make sure you do not pick at the scabs because prematurely removing the scabs may cause hyper-pigmentation or scarring.
If the area is still irritated at the end of the night you may apply some Neosporin or medicated powder. Keep the area dry during the day.
Must use sun protection in the day all year round. (SPF 30 or above)
Avoid direct sunlight during the peak hours (11am-5pm).
When cleansing the face or showering, use mild products without alcohol.
Pat the area dry instead of rubbing to prevent removal of the scab.
Do not use any other form of peeling or bleaching products for at least 21 days.

The above information is true and accurate to the best of my knowledge.

Patient Signature:

Date: