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GFE for Laser Hair Removal
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Is the PT 18 years of age or older?
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Is Patients parent or legal guardian present
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Does patient have any Medical Conditions?
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If YES, please list:
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Does patient take any medications?
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If YES, please list:
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Does patient have any allergies?
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If YES, please list:
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Is patient pregnant or breastfeeding?
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1. Use of photosensitizing medication (topical or oral)
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If YES, name of medication & when last used
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2. Is skin currently darker than natural from sun, tanning bed, self tanner?
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If YES, advised patient increased risk
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3. Does patient have infection, inflammation or open wounds?
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4. History or hyper or hypo-pigmentation?
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If YES, advised patient increased risk
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Patient verbalized understanding to this warning
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5. History of abnormal reaction to sunlight, laser or light-based treatments
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6. History of slow or delayed wound healing or hypertrophic/keloid scarring?
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If YES, advised patient increased risk
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Patient verbalized understanding to this warning
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7. History of Herpes infections?
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If YES, current outbreak?
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Advised patient increased risk of herpes outbreak
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Patient verbalized understanding to this warning
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8. History of seizures triggered by light?
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9. Recent wax or depilatory cream use?
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If YES, advised patient increased risk
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Patient verbalized understanding to this warning
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10. Active skin diseases (psoriasis, vitiligo)
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11. Diseases which may be stimulated by light (lupus)
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12. Use of topical skin products containing acid or chemical peel within 2 weeks?
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If YES, which product and when
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If less than one week ago, is skin having following reactions from topical products?
• • •
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If YES, advised patient increased risk
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If NO, has it been less than 3 days?
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If YES, advised patient increased risk
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Patient verbalized understanding to this warning
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13. Current use of anticoagulant medication?
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If YES, prescribed by a provider or taking medication by their own choice?
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Patient verbalized understanding to this warning
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Bleeding or clotting disorder?
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If YES, which one:
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Additional Comments
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Standing Orders:
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Discussion with Patient
• • •
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Signature of Patient
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I approve this patient for the requested procedure(s) as noted in this document
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Name/Signature of NP/PA/MD
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