Laser /IPL Telephone / Video Consultation Form

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Home phone* This field is required.
5
Mobile phone* This field is required.
6
Occupation* This field is required.
7
Are able to phone you should we need to discuss your appointment?* This field is required.
Yes
No
8
Are we able to email about your appointment?* This field is required.
Yes
No
9
Are you happy for us to text you about your appointment?* This field is required.
Yes
No
10
Would you like to receive our newsletter by Email (usually monthly)?* This field is required.
Yes
No
11
Treatment requested* This field is required.
Hair Removal
Thread Vein / Vascular removal
Pigmentation
Tattoo Removal
12
Lifestyle & Medical History – please tick any that apply to you. If you do not understand or recognise the condition then please discuss this with your laser/IPL operator* This field is required.
Pregnant or planning pregnancy
Suntanned/Using sunbeds or fake tan
History of cancer or chemo/radiotherapy
Diabetes
Lupus
History of keloid formation/scarring
Photosensitive conditions
Epilepsy
Communicable Diseases (Hepatitis/HIV)
Lymphatic/Immune System Disorders
PCOS/Hormonal Imbalance
Thyroid Condition
Psoriasis/Eczema
Steroid Therapy
Herpes (shingles/cold sores)
High Blood Pressure
Depression/Anxiety
None of the above
Other
13
Please can you comment about above and any other medical problems.
14
Are you currently taking any medication or any supplements?* This field is required.
Yes
No
15
If yes please specify the condition and the medication:
16
Are you currently using/used in the last 3 months any of the following?* This field is required.
St Johns Wort
Gold Medications
Antibiotics
Anticoagulants
Roaccutane
Retin A
Amioderone
Steroids
None of these
17
Are you recovering from any major medical treatment within the last 6 months? * This field is required.
Yes
No
18
Has the area for treatment ever had any of the following? * This field is required.
Moles
Birthmarks
Tattoos
Permanent Make-up
None of these
19
Has the area for treatment had any of the following procedures? * This field is required.
Chemical Peel
Botox
Injectable Fillers
Previous laser or IPL Treatment
Silhouette Soft Threads in the last 10 weeks
None of these
20
Has the area had a sun/sunbed exposure causing a tan in last 4-6 weeks?* This field is required.
Yes
No
21
If so has your tan faded?
Yes
No
22
What products do you currently use on the treatment area?* This field is required.
23
What are your goals/expectations for the treatment?* This field is required.
24
Ethnic origin* This field is required.
25
Please think about how your skin responds to midday summer sun exposure with no sunscreen:* This field is required.
Skin Type 1 Always burns, never tans
Skin Type 2 Easily burnt, eventually gets a moderate tan
Skin Type 3 Sometimes burns, quickly gets average tan
Skin Type 4 Rarely burns, quickly gets a deep tan
Skin Type 5 Very rarely burns, consistent tan
Skin Type 6 Never burns, consistent tan
26
How much do you smoke/day?* This field is required.
27
How much alcohol do you consume a week ?* This field is required.
28
Do you have any allergies? If so what are you allergic to?* This field is required.
Yes
No
Other
29
Is there any possibility of pregnancy or are you breast feeding?* This field is required.
Yes
No
30
If no, how long have you been considering treatment for?* This field is required.
31
Out of 5, how familiar are you with laser /IPL Treatment ? * This field is required.
1
2
3
4
5
Worst
Best
32
Out of 5, where 5 is very much and 0 is not at all. How much does you problem bother you?* This field is required.
1
2
3
4
5
Worst
Best
33
Can you explain why it bothers you?
34
Where 5 is very much and 0 is not at all. How much do you think it affects the following?
35
Your confidence * This field is required.
1
2
3
4
5
Not at all
Very Much
36
Your social life * This field is required.
1
2
3
4
5
Not at all
Very Much
37
Your employment or role at work * This field is required.
1
2
3
4
5
Not at all
Very Much
38
How much does it impact you psychologically* This field is required.
1
2
3
4
5
Not at all
Very Much
39
Does/ will your treatment help you psychologically?* This field is required.
Yes
No
40
Does/ will your treatment help you in any other way?* This field is required.
Yes
No
Other
41
Do you worry about your appearance* This field is required.
Yes
No
42
Do you suffer from anxiety symptoms or low mood or nay other mental health problems?* This field is required.
Yes
No
43
Any other comments:
44
The information I have given is correct to the best of my knowledge, and I have not withheld any medical state or information. I will inform the IPL/Laser Technician before treatment if there has been any change (for example in medications).
Clear
Should be Empty: