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Laser Consultation
Laser Consultation
Personal Details
Name
*
Date Of Birth
*
Gender
*
Male
Female
Email
*
Phone
*
Address
*
How did you hear about us?
*
...
Word Of Mouth
Search Engine (i.e Google)
Newspaper
Radio
Other
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:
*
Caucasian
Mediterranean
Asian
Middle Eastern
African American
North American
Hispanic
Mixed Race
Other
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:
*
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)
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:
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