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Yonge Eglinton Laser Eye +Cosmetic Centre

2345 Yonge Street, Suite 212
Toronto, Ontario, M4P 2E5

Ph. 877-950-1414
Fx. 416-545-0049

Recognized for Laser Eye surgery by the Toronto Sun

Cosmetic Care at Yonge Eglinton Laser Eye & Cosmetic Centre

Yonge Eglinton Laser Eye & Cosmetic Centre offers cosmetic procedures including laser hair removal and BOTOX® treatments. Toronto residents can also choose from a wide range of eyewear solutions.

To allow us to better serve your cosmetic needs, we ask that you complete the following patient information form. The information that you provide will help us review your candidacy for our cosmetic procedures.

After submitting the form you will be contacted by a member of the staff at Yonge Eglinton Laser Eye & Cosmetic Centre.

	* indicates a required field
Date*:	(mm/dd/yyyy)
Name*:
Address*:
City*:
P.C./Zip*:
Telephone*:
E-mail Address*:
Occupation*:

How did you hear about us? (Please specify)	Sun Metro Z103.5 FLOW 93.5 97.3 EZRock Yellow Pages Flyer TV Internet Friend/Family Member Name:
Which do you use?	Tanning Beds Tanning Lotions
What areas are you interested in having treated?
Check any of the following that apply to you:	Diabetic Pregnant Plan to get pregnant in the near future Had sun exposure/used tanning beds in the past four weeks Wear self-tanning creams Wear a pacemaker History of cold sores Smoke Bruise easily
Are you taking any medications?	No Yes If yes, please list:
Do you have any medical condition that you are being treated for?	No Yes If yes, please explain:
Have you ever been on Accutane®?	No Yes If yes, when was the last time:
Do you have any allergies? (Medications/skin/food)	No Yes If yes, please list:
What is the natural colour of the hair in the area you are interested in treating?
Do you form keloids or excessive scarring?	No Yes
Do you have any moles or tattoos	No Yes
Have you ever had laser hair removal before?	No Yes

Questions within this section to be completed by females only
Could you be pregnant?	No Yes
Have you ever been checked for hormonal abnormalities?	No Yes
Have you ever been on fertility drugs?	No Yes
Have you ever been on drugs to stop hair growth?	No Yes
Are your menstrual periods regular?	No Yes

Select ONE description that would characterize your reaction to the sun without sunblock:	I always burn and never tan I always burn and sometimes tan I sometimes burn but I always tan I rarely burn but always tan I have moderately pigmented skin I have darkly pigmented skin
Do you wear sunscreen?	Never Sometimes Always On vacation
Have you used any of the following methods in the treatment area?	Shaving Waxing Sugaring Tweezing Electrolysis Bleaching Chemical depilatories Laser When was this last done?

If you are considering BOTOX® treatments, laser hair removal, or any of the cosmetic procedures offered at Yonge Eglinton Laser Centre + Cosmetic Centre, complete a patient information form.

Yonge Eglinton Laser Eye & Cosmetic Centre
2345 Yonge Street, Suite 212
Toronto, Ontario, M4P 2E5

Toronto-laser.com is a part of DocShop, an online resource that provides information about typical patient results after laser vision correction.