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    Photos must be submitted (where applicable) - 

     

    either at the end of this form OR, by email to

    info@infinitylaserclinics.com 

    or Whatsapp to 07904 855014.

     

    Please note that you will be contacted by text during normal office hours Mon-Fri to arrange your free telephone consultation. If we do not hear back from you, we shall assume that you no longer require further contact. 

     

     

     

     

     

     

     

     

     

     

     

  • About You

  • * Your details are for clinic use/aftercare & appointment confirmation contact only. Marketing will NOT be sent.

  •  -

  • Medical Assessment - Contraindications

    Answer all questions accurately and give details where applicable
  • Are you pregnant / planning to be pregnant or currently breastfeeding?*
  • Are you taking any prescribed medication?*
  • Have you taken Roaccutane (acne medication) within the past 6 months?*
  • Do you have cancer?*
  • Have you previously had cancer?*
  • Do you suffer from Epilepsy?*
  • Do you use sunbeds?*
  • Are you currently tanned?*
  • Do you have any raised (Keloid) scars?*

  • Medical Assessment - Cautions

    Answer all questions accurately and give details where applicable
  • Have you undergone surgery within the past 6 months?*
  • Are you Diabetic?*
  • Do you suffer from any Hormonal related disorders?*
  • Do you suffer (previously/currently) from Cold Sores / Herpes Simplex?*
  • Are you currently having any chemical peels or microdermabrasion at the area(s) to be treated?*
  • Have you recently (within past 2 weeks) had injectable fillers or BOTOX at the area(s) to be treated?*
  • Do you easily burn in the sun?*
  • Do you suffer from excessively dry or sensitive skin?*

  • Medical Assessment - General

    Answer all questions accurately and give details where applicable
  • Do you suffer from any allergies?*
  • Do you suffer from any medical / dental conditions?*
  • Are you currently receiving any medical / dental treatment?*
  • Do you have any implanted medical devices or metal plates?*
  • Are you taking any over the counter medications or vitamins / herbal supplements?*
  • Do you have Thrombosis (DVT)?*
  • Do you suffer from any Vascular or Respiratory problems?*
  • Do you suffer from any Autoimmune disorders?*
  • Do you suffer from Depression, Anxiety or any other mental health / psychological conditions?*
  • Do you have any other medical condition, injury or anything else we should be aware of that we have not covered?*

  • History

  • 1b) Have you previously had professional treatment / tried over the counter products?*
  • 2) Have you been diagnosed or treated for Rosacea or any other skin conditions at the area(s) to be treated?*
  • 3) Have you used any topical products with active ingredients within the last 5 days (Retinols / AHA's / Glycolic / Steroid creams / Antibiotic creams etc.) at the area(s) to be treated?*
  • 4) Do you use SPF? (sun protection)*
  • 5) Do you smoke cigarettes / cigars? (Vaping does not apply)*
  • 6) Does your skin colour differ from your parents?*

  • Declaration

  • Data Protection

  • Photos

    Please take clear photos (if you are using your phone or tablet to complete this form) of the area(s) of concern you would like to consider for treatment. Otherwise, please submit a photo/photos by email (info@infinitylaserclinics.com) OR by Whats App or text to 07904 855014. Your images will not be shared with anyone else; we are using them as a reference to assist with your consultation. We only need ONE image for ONE lesion/area/Venous Lake etc.
  • Image 1
  • Image 2 (if applicable)
  • Image 3 (if applicable)
  • Image 4 (if applicable)
  • Image 5 (if applicable)

  • Once you have completed your form, please submit immediately.  Thank you!

  • Date Form Completed*
     / /
    2 digit day, 2 digit month, 4 digit year
  • How did you hear about us?*
  • Should be Empty: