Smoking Intake Form

Note: Imagine Laserworks® cannot accept clients who are pregnant.

The user has read, understands and agrees to the following:
Imagine Laserworks® does not diagnose or treat any disease or medical condition. The Imagine Laserworks system is non-medical in nature and therefore may not be covered by medical insurance plans. Imagine Laserworks® and its owners, officers, directors, managers, employees and franchise operators are held harmless of any and all liability related to the Imagine Laserworks system. Imagine Laserworks® does not issue any guarantee or promises regarding individual results.

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City Province Postal Code

Which tobacco products do you currently use?*

Please name the condition(s) we should be aware of:*

Over the last month, how much did you smoke on average per day?*

Have you tried to quit before?

Yes
No

Why do you believe you were unable to quit? Or if you did quit, why did you resume using tobacco?

Have you ever been told by a doctor that you need to quit?*

Yes
No

What was the reason you were told to quit?

Do you have any health concerns that may be related to smoking?*

Yes
No

Please describe your health concerns.

When do you smoke?*

Why do you want to quit at this time?*

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