Laser Consultation

Personal Details

Name*

Date Of Birth*

Gender*

Male
Female

Email*

Phone*

Address*

How did you hear about us?*

Medical Consent

Your GP's Name:*

Your GP's Address*

Emergency Contact Name*

Their Phone Number*

Their Relationship To You*

Medical Assessment

What laser treatment are you interested in?*

Hair removal
Pigmentation removal

Have you ever been treated here before?*

Yes
No

Do you have any serious health conditions?*

Yes
No

Have you suffered from Epileptic fits?*

Yes
No

Do you have any allergies?*

Yes
No

General Assessment

Please tick the appropriate box below

Your genetic background affects your skin and its response to the laser or IPL. Please specify your ethnic origin:*

When you sunbathe how does your skin respond?*

Always burn, never tan
Usually burn, sometimes tan
Never burn, always tan
Sometimes burn, usually tan

Have you sunbathed, used sunbeds or developed a tan darker than your usual skin colour (even from walking around or sitting in the sun) in the last 6 weeks?*

Yes
No

Are you planning on a holiday soon?*

Yes
No

Have you used self-tanning products in the last 3 weeks?*

Yes
No

Do you have any implants, tattoos or permanent makeup in/on the area to be treated?*

Yes
No

Have you ever used or had Renova or Retin A, Alpha hydroxyl, Glycolic Acid or other cosmetic peels?*

Yes
No

Have you ever had Botox or fillers?*

Yes
No

Have you ever had laser resurfacing procedures (particularly on the face)?*

Yes
No

Are you wearing any kind of perfume in the area to be treated?*

Yes
No

Have you ever had a skin problem or been under the care of a dermatologist?*

Yes
No

Are you using Environ / DMK or similar on the area being treated?*

Yes
No

Are you on Skin Vitamin A or any Vitamin A product/tablets?*

Yes
No

Do you take any medications, drugs or over the counter preparations/remedies?*

Yes
No

Medical History

To help give the best possible care, please carefully read and tick all that apply to you from the list below:*

If you have ticked any of the above boxes, please where possible list date diagnosed or treated below:

Have you had any prior hospitalizations and surgery in the last 5 years?*

Yes
No

For your consultation what would you prefer?*

Zoom / WhatsApp Call Option
Email Option

Do you consent to us using your before & after photos? (your identity will be protected)*

Yes, I Agree
No, I Do Not Agree

I hereby declare that the information provided is true and correct to the best of my knowledge.

Consultation Fee*

Price:

Total

€ 0.00

Card Details*

Card Details

Cardholder Name

Cancer / Skin Cancer
Acne
Roaccutane in last 6 months
Psoriasis
Rosacea
Eczema
Vitiligo
Port Wine Stain
Herpes
Cold Sores
Shingles
Lupus Erythematosus
Photosensitive Reactions
Cold Sensitivity / Raynaud's
Burns / Skin Grafts
Keloid Or Overgrown Scars
Tattoos / Cosmetic Tattoos
Permanent Makeup
Do You Smoke
Taking Protein Supplements
Allergy To Local Anaesthetic
High Blood Pressure
Heart Disease
Implants (Metal Or Other)
Pacemaker / Defibrillator
Blood Or Bleeding Disorder
Blood Transfusion
Lymph Gland Disorder
Stroke
Thrombophlebitis
Duodenal / Peptic Ulcer
Colitis / Other Intestinal Disease
Liver Or Gallbladder Disease
Lung Disease
Tuberculosis / Pleurisy / Other
Urinary Or Bladder Infection
Venereal Disease
Hepatitis
HIV / Aids
Frequent Infections
Kaposi's Sarcoma
Body Dysmorphia
Eye Disease / Glaucoma / Cataract
Diabetes
Neurological Disorder
Emotional / Psychiatric Disorder
Claustrophobia
Seizures / Epileptic Fits
Arthritis / Bone Disorder
Gold Therapy
Endocrine Disorders
Hirsutism
Polycystic Ovary Syndrome
Thyroid Disease
Hormone Replacement
Precocious Puberty
Epidermolysis Bullosa
Are You Pregnant?
Or Planning A Pregnancy?
Are You Breastfeeding?
Vaginal Yeast Infection?
Other (please specify below)

Personal Details

Medical Consent

Medical Assessment

General Assessment

Medical History

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