Infinity Laser Clinics Consultation Form

This form will take a few minutes to complete.

You must please attach (at the end of this form) OR send clear photo(s) of what you want to be treated (unless it is the intimate area) by email to info@infinitylaserclinics.com or Whatsapp / Text to 07904 855014.

You will be contacted by text during normal office hours to arrange your free telephone consultation.

***PLEASE NOTE that we are having a short break over Easter and will contact you on Tuesday 7th April

Please save 07904 855014 as LASER

If you have any questions whilst completing this form, please text 07904 855014.
Yes
About You
* Your details are for clinic use/aftercare & appointment confirmation contact only. Marketing will NOT be sent.
Full Name*

First NameLast Name
Address*

Address Line 1

Address Line 2

Town/City

Post Code
E-mail*
Mobile Phone No.*

E.g: 07904E.g.855014
Date of Birth*

DayMonthYear
Name & Number of who to contact in case of an emergency:*
Name & Telephone Number of anyone who should be contacted should you become unwell whilst in clinic
Your Current Occupation / Retired From:*
How did you hear about us?*
Google / clinic name / friend
Medical Assessment - Contraindications

Answer all questions accurately and give details where applicable
YesNo
Please provide details
If you answer yes to this question, you are unsuitable for treatment and will be directed to the end of the form
YesNo
Please provide details of medication and what it is used for:
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
YesNo
Please provide details
Medical Assessment - Cautions

Answer all questions accurately and give details where applicable
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
Medical Assessment - General

Answer all questions accurately and give details where applicable
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
History
1a) What would you like to achieve from the treatment(s) we can offer?*
Example: Smoother skin / Tattoo removal / Reduce sun damage etc...
YesNo
1c) Please provide specific details:
Example: Laser tattoo removal 5 years ago / Skin brightening cream 6 months ago.
YesNo
2a) Please provide specific details:
Example: I have eczema on my knees and use topical Steroid cream
YesNo
3a) Please provide specific details:
Example: My night repair serum contains Retinol
A dedicated SPF 30 or 50 every dayI use a daily moisturiser with SPF in itOnly in Summer / AbroadOccasionallyNever
YesNo
YesNo
6a) Please provide details:
*This can affect your treatment protocol & progress - please detail if applicable.
Declaration
I agree that all of the Medical Assessment & History questions that I have answered and subsequent information that I have provided within this form is accurate and true. I understand that if I have given false information or withheld any information, that this may cause a health risk to myself including post treatment adverse reactions, healing complications and my overall results for which Infinity Laser Clinics cannot be held responsible.
Data Protection
At Infinity Laser Clinics, we have always taken your data protection very seriously and as the new GDPR legislation commenced on 25/05/18, we want to ensure you that we continue to take care in how we communicate with you. Your contact details will have been provided by you, either by booking an appointment through one of our ‘host’ clinics or with us directly at Infinity Laser Clinics either via telephone, social media platforms or websites. For this reason, we are assuming that there is a legitimate reason and interest for contacting you. If you are happy with this and wish to receive confirmation of your appointments and follow up contact post treatment then you do not need to do anything. (This may be sent by SMS or email and occasionally via landline telephone should we not have the former means of contact.) If you prefer to be removed from the list please email info@infinitylaserclinics.com If you have a test patch or treatment, by law – for accounting, auditing and insurance purposes, we must hold your records for six and ten years respectively although this does not mean that you will be contacted in the future. Where there has only been a consultation and no further test patch/treatment/appointment booked, your records will be destroyed after 6 months. All online forms and paperwork that we hold is stored securely and in locked filing cabinets, all clinical images are stored on a secure home office computer / clinical iPad and all electronic devices are locked away when not in use. All transportation of paper files containing medical history and personal information is carried in locked storage as is our diary and camera. We do not share your details with anyone other than the host clinic at which you came to see us (for their appointment scheduling / progress of treatment records). If they wish to market you independently, they must request your consent separately. The information you have given to us is for the sole purpose of recording your consultation, test patch and, if applicable, your treatment(s) - laser energies and progress. All photographs that we take are used to measure before, during and after treatments, in addition to final results. To view our PRIVACYPOLICY, please visit: www.infinitylaserclinics.com
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!
Signature*

Clear
Date Form Completed*

DayMonthYear
Medispa S10True YouVanity RoomsKatrina TootellSally WagstaffInfinity Laser Clinics direct
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About You

Medical Assessment - Contraindications

Medical Assessment - Cautions

Medical Assessment - General

History

Declaration

Data Protection

Photos