Washington Institute of Dermatologic Laser Surgery
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New Patient History (Form 2/4)

Full payment is due at the time services are rendered. A fee of $250 will be charged for any missed, rescheduled, or cancelled appointments with less than 48 business hours notice. A non-refundable deposit of $1000 is required to schedule major procedures.

Prior Cosmetic Procedures
Do you have a history of oral cold sores?
Do you have a history of HIV?
Do you have a history of Hepatitis?
Do you have a history of skin cancer?
Do you suffer from hay fever/eczema/allergic rhinitis?
Do you suffer from any medical condition affected by flashing or flickering lights?
Have you had any dental work or vaccines administered in the last two weeks?
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