Cyspera Consultation Form

Cyspera Consultation Form
Thank you for your interest in Cyspera cream.

At Cheshire Lasers, we provide Cyspera consultations 7 days a week and we are available till 8 pm Tuesday to Thursday.

Please can you complete the following form and we can arrange a phone call consultation at your earliest convenience.
Name*

First NameLast Name
Email*
example@example.com
Please enter your phone number*
Have you used Cyspera before?*
Who has recommended Cyspera to you?*

DermatologistGPSkin ClinicFriendInformation on the internetSocial MediaOther
Where about is your pigmentation? What do you think the cause is? *
Which products have you been using on your skin over the last month?*
Have you used the Obagi Nuderm system or any other products containing Hydroquinone in the last 2 months?*

YesNo
Are you using any products containing tretinoin, retinol, glycolic acid, salicylic acid or any other acids?*

YesNo
Please advise which other products you have tried in the past to treat your pigmentation.
Are you pregnant or breast feeding?*

YesNo
Do you suffer from Vitiligo?*

YesNo
Do you regularly use and SPF30 or more on the problem area ?*

YesNo
Please read the instructions on how to use Cyspera.
At Cheshire Lasers, we provide Cyspera consultations 7 days a week and we are available till 8 pm Tuesday to Thursday. When are you available for a consultation?*
Please confirm what you have told us is correct and that you have read the instructions detailing how to use Cyspera.*

YesNo
Important Information about Cyspera:

Daily treatment with Cyspera Intensive is required for 16 weeks to achieve the best results.

A 30g tube of Cyspera Intense will often not last for 16 weeks of treatment.

If you are concerned about the cost, we recommend you use Cyspera Intense on a small area to trial it and allow you to evaluate your response before treating the full area you are concerned about.

Cyspera Intense is a very effective treatment for reducing pigmentation and melasma; however, it does not always work, and sometimes it only fades the pigmentation.

Unless you continue to treat the pigmentation, use SPF and stay out of the sun, the pigmentation will come back.

Cheshire Lasers is a supplier of Cyspera and can not guarantee results.
I have read the information above. I am aware a 30g tube will not last the full 16 weeks, and I am also aware that the response to Cyspera varies and that Cheshire Lasers does not guarantee results.*

YesNo
Should be Empty: