Consultation Form
This form is designed to obtain the necessary information prior to your visit so you can be assessed for suitability for advanced cosmetic treatment. Please complete the required fields below and if possible attach a photo. Your personal information is strictly confidential.
Your Details
Gender
*
Male
Female
N/A
Full name
*
Age
*
Email
*
Confirm Email
*
Phone
Your Condition
Treatment
*
MOLE
SKIN TAGS
FACIALTHREAD VEINS
BLOOD SPOTS
SPIDER NAEVI
MILIA
XANTHELASMA
SYRINGOMA
SEBORRHOEIC- KERATOSIS
DERMATOSIS PAPULOSA
PLANE WARTS
VERRUCAE
FILIFORM WARTS
AGE/SUN/LIVER SPOTS
SEBACEOUS-HYPERPLASIA
UNDIAGNOSED NOT SURE
When was it last seen by a Doctor?
LAST 6 MONTHS
WITHIN A YEAR
WITHIN 2 YEARS
MORE THAN 2 YEARS
NEVER
How long have you had this condition?
UNDER A YEAR
1 OR 2 YEARS
3 TO 5 YEARS
AS LONG AS I CAN REMEMBER
I DON'T KNOW
Are you Diabetic
YES
NO
Prefered location
HARROGATE
BRADFORD
How long have you been considering treatment
MONTHS, YEARS
Additional Details: whereabouts on the body is this condition.
PLEASE SHARE ANY OTHER DETAILS THAT MAY BE USEFUL FOR THE THERAPIST TO KNOW
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