Appointment and consultation form

Appointment/ Consultation/ Medication form

(日本人の方は日本語の方のフォームにてご送信をお願い致します。)
Full Name

First NameLast Name
Address: (If you are already an existing client, you do not need to fill out this form unless your address has changed.)

Street Address

Street Address Line 2

CityState / Province

Post Code
Mobil phone
Profession
Date of birth
E-mail

Confirmation Email
How did you hear about us? e.g introduced by (friend's full name)
Have you been treated by us before?
Are you on medication? (Hormonal Pill inc Birth Control Pill, Ibuprofen, Antibiotics, Hay fever pill, Steroid, St. John’s Wort, Supplements, ALL OTHERS). Do you have Any health issues, skin issues, Past operations, Any Allergies?Have you had any beauty treatments in the past 3months?
If yes, please provide the details. If not, please write "None"
Have you recently had a sun tan or fake tan?
If yes, please write specifically. ⚠️Please report correctly even if you have a slight suntan. There are individual differences until the suntan completely disappears. Sun exposure increases the risk of treatment especially IPL skin Rejuvenation or Lasers. We will need power setting control by your declaration.
What is your original skin color? Fitzpatrick skin type?
What is your concern?
Treatment : All information on prices, times, treatment detail can be found under 'Treatment' on our website. Due to limited space, PLEASE choose your required treatment. Do not make a mark if you haven't decided yet otherwise you may be charged the cancellation fee on the day. Total treatments shouldn’t be over 2hs.
Laser Hair Removal - *please state your body parts below. (Please shave the area a day before your treatment. Hair should be 0.5mm - 1mm on the surface of the skin. Please be careful if your hair is more than 2mm as it can be more painful and may cause treatment to not work properly.) *25% added for gentleman's body
Opening hours: Every Tuesday ~ Saturday 10:30am ~ 6:30pm Closed Sunday and Monday.

※We accept bookings up to a month in advance.

Please fill in 3 preferable dates and times otherwise you will not able to send this form.
※PLEASE make sure your day and times are during our opening hours (see above).

DayMonthYearHourMinutesAM/PM Option
2nd Date and Time

DayMonthYearHourMinutesAM/PM Option
3rd Date and Time

DayMonthYearHourMinutesAM/PM Option
Due to limited space, please state all your times of availability. If your request dates are fully booked already, you will need to send this form again.
Terms and Conditions
Signature
Should be Empty:

Appointment/ Consultation/ Medication form