Skip Navigation

1420 West Canal Ct., Suite 180, Littleton, CO 80120

NEWSLETTER (opens in new tab)(opens in new tab)(opens in new tab)(opens in new tab)(opens in new tab)

About
- About Us
- Our Team
Services
Products
Specials
Gallery
Blogs
For Clients
- Payment Options
  - Care Credit
  - Cherry
- Testimonials
Contact Us
NEWSLETTER
(303) 470-0200

Skip Main Content

Client Demographics

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

Email

Please complete this field.

Today's Date:

Please complete this field.

Client Demographics

Client Demographics

Client’s Name:

Please complete this field.

DOB:

Please complete this field.

Age:

Please complete this field.

Gender:

Please select an option.

Address:

Please complete this field.

City:

Please complete this field.

State:

Please complete this field.

Zip Code:

Please complete this field.

Home / Mobile:

Please complete this field.

Work:

Please complete this field.

Would you like Text reminders?

Please select an option.

If Yes, list your Phone Carrier:

Please complete this field.

Would you like to receive newsletters regarding our specials and discounts on services and products?

Please select an option.

Please list your email:

Please complete this field.

Would you like email reminders for appointments?

Please select an option.

Occupation:

Please complete this field.

How did you hear about us?

Please complete this field.

Who may we thank for referring you?

Please complete this field.

What is the reason for your visit?

Please complete this field.

Emergency Contact

Emergency Contact

Name:

Please complete this field.

Relationship:

Please complete this field.

Home / Mobile

Please complete this field.

Work:

Please complete this field.

In case of emergency, are we able to release medical information regarding your case to the listed contact above?

Please select an option.

Please check off all services that are of interest to you

Please check off all services that are of interest to you

Acne/Rosacea

Light Therapy

Aesthetics (Skin Care)

Anti-Aging

Skin Tightening

Wrinkle Reduction

Botox

Filler

Hair Regeneration

Laser Hair Removal

Laser Treatments

Micro-needling

Light Therapy

Medical Weight Loss

Vaginal Rejuvenation

Sexual Enhancement

Women’s Health

Bio-Identical Hormones

Body Sculpting

Weight Management

Eyelash Growth

Urinary incontinence, dryness, painful sex, laxity

Medical History

Medical History

Please check the following that pertain to your present health / past medical history:

Allergies/Sensitivities

Artificial Joint

Atherosclerosis

Bruise Easily

Carpal Tunnel Syndrome

Contagious Skin Condition

Anemia

Frequent Colds & Flu

Deep Vein Thrombosis/Blood Clots

Diabetes

Epilepsy

Headaches/Migraines

Heart Condition

Hemophilia

Rheumatoid Arthritis

Open Sores/Wounds

Nervous Disorders

Pregnancy

Pregnancy Months

Please complete this field.

Phlebitis

Shortness of Breath

High/Low Blood Pressure

Hepatitis

Kidney Disease

Sprains/Strains

Swollen Glands

Thyroid Problems

Osteoporosis

Tuberculosis

Fibromyalgia

Hearing Aid

High Fevers

Allergies/Sensitivities

Stroke

Keloid Scars

Mental Illness

Acutane

TMJ

Claustrophobia

Herpes Outbreaks

Vein Problems

High Cholesterol

Arthritis

Nervous Disorders

HIV

Insomnia

Multiple Sclero

Obesity

Acne

Latex Allergy

High Fevers

Contact Lenses

Dermatitis/Eczema

Frequent Sinus Infections

Pacemaker

Skin Rashes

Other

Please complete this field.

Subscribe to updates from Renu Laser & Skin Care

Thank you for subscribing!

You will receive important news and updates from our practice directly to your inbox.

Thanks!

Your form has been successfully submitted!

We will be in touch with you if additional information is needed.

Thanks!

Opt-out of using e-signatures?

Are you sure you want to opt-out of using e-signatures? You will be required to fill this form out again during your visit on a paper copy.

Download a copy of your signed form

Click the button below to download a PDF copy of your form

QUICK LINKS
SERVICES

1420 West Canal Ct., Suite 180,
Littleton, CO 80120

(303) 470-0200 Request Appointment

POWERED BY

(opens in new tab)

Privacy Policy(opens in new tab)Data Security(opens in new tab)HIPAA(opens in new tab)Terms of Use(opens in new tab)

Copyright 2024 Renu Laser & Skin Care