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*

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?*

YesNo
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?*

YesNo
If yes, please provide the details. If not, please write "None" *
⚠️ Have you received the Covid-19 vaccine within the last two weeks? No appointment for 2 weeks before and after Covid-19 vaccination due to side effects.
Have you recently had a sun tan or fake tan?*

Yes (Sun tan)Yes (Fake tan)No
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.*

Consultation Only £30 15min(Free of charge if you made the treatments appointment on the same day, immediately after the consultation.)IPL x RF Skin Rejuvenation SR or SRA "stronger" Face £280IPL x RF Skin Rejuvenation SR or SRA "stronger" Hands (excluding fingers) £220Refirm ST £250Matrix IR £250DuoST (IPLxRF Skin Rejuvenation x Refirm ST) £450DuoIR (IPLxRF Skin rejuvenation x Matrix IR) £450Trinity (IPLxRF Skin Rejuvenation xRefirm STxMatrix IR) £550Spider Vein Removal around nose £150eMatrix~Fractional Skin Resurfacing full face £450eMatrix~Fractional Skin Resurfacing- around eye/forehead/around mouth/chin/neck line -each £260Refirm ST eye Treatment £150Accent XL Face £250Accent XL Face x IPLxRF skin rejuvenation SR or SRA £480Skin Peel Facial £110Cryo Non-needle-Mesotherapy £110Skin Peel Facial x Cryo Non-needle-Mesotherapy £160Dermal Filler (HA) £290◆◆◆ You can add options to your facial ◆◆◆Skin peel +£50Cryo Electrorporation non-needle mesotherapy +£50Refirm ST Eye Treatment +£110)
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.)

Under Arms £65Hands and fingers £65Feets & toes £65Full face £150Around mouth (ladies) £65Beard around mouth (gentleman) £100Jawline (gentleman) £100Neck -front or back £100Neck-front and back £150Around mouth x Jawline (gentlemen) £130Jawline x front neck (gentlemen) £130Around mouth x Jawline x Front neck £150Around bellybutton £65Lower half arms £130Upper half arms £150Full arms £200Chest £150Nipples £65Abdomen £150Buttock £150Lower legs £150Knees £65Thigh (without back of thigh) £200Thigh (with back of thigh) £250Full legs (without back of thigh) £300Full legs (with back of thigh) £350Half back £150Full bacK £250Bikini (please wear WHITE knickers only as laser can be absorbed by coloured underwear) £80Full bikini without anal £130Full bikini with anal £150
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*

① You must give us the full details of any health issues and medications to minimize the risk of any side effects. If your situation changes, you must let us know before the treatment.② You must read and understand all the information on the website regarding your chosen treatment, including pricing, before booking.③ Due to limited space, a cancellation fee of £50 applies if the cancellation is within 48 hours of your appointment. If your canceled booking was for more than 1 hour, you will be charged £100. If you are late, the treatment time will be shortened or you have to cancel one of the treatments and you will be required to pay a cancellation fee of £30 and the other normal treatment fees.④ If you change the appointment more than twice, we will charge you £50 or £100 for treatments over 1 hour⑤ We will not take your appointment again if you cancel without notice.⑥ We accept card payment only (Visa, MasterCard, Amex, JCB, Apple Pay).⑦ I have read and understood all the terms and conditions above ①〜⑥, and I’ve read all explanations about treatments on the website. I would like to make an appointment.
Signature*

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Appointment/ Consultation/ Medication form