Form | Jeena Clinic

Services
Laser Hair Removal
- For Men
- For Women
Our Work
Contact Us
General Information
Offers
Online Booking
Form
Booking Policy

For laser hair removal appointments only, please shave the treatment area 24 hours beforehand.

Cancellation/Reschedule Policy

Cancellations or reschedules with less than 24 hours notice will incur a fee.
If you are more than 15 minutes late, a fee will be applied or your prepaid service will be deducted. We will try our best to reschedule your appointment at your convenience.
In case of emergencies, please call 0470604054 or 0413175388.
Pre-Treatment Instructions (Laser Hair Removal Only)

Note: Shaving is only required for laser hair removal appointments. There is no shaving requirement for other services.

Patient Intake Form

Patient Details

First Name

Last Name

Patient Age

Patient Gender

Phone/Mobile

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Emergency Contact Details

Please enter your emergency contact details.

First Name

Last Name

Emergency Person Relationship

Emergency Person Phone/Mobile

Emergency Person Email

Type of Service

Please answer the questions accordingly.

Type of Service

Conditions & Allergies

Please answer the questions accordingly.

Do you have any allergies?

Yes

No

Please list your allergies (e.g. latex, metals, shellfish, nuts, any other..)

Do you have any scar(s) on your skin?

Yes

No

Please briefly explain the scar type and area.

Are you currently experiencing any active skin conditions?

Yes

No

Please list your skin conditions in details

Are you currently taking or have taken any medications or supplement in the past 3 months?

Yes

No

Please list in details

Have you had any procedures in the last 2 weeks on the area to be treated with Dermapen (Micro-Needling)?

Yes

No

Please list in details

Are you currently pregnant or breastfeeding?

Yes

No

Consent

Please answer the questions accordingly.

By signing below, I understand and agree to the following:

The information I provide on this form will be used by Jeena Clinic.
This information includes my medical history, medications, allergies, and other personal data.
I have provided accurate and up to date information.

Signature

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