New Patient Enquiry Form

New Patient Enquiry Form.

Cheshire Lasers
Full Name*

First NameLast Name
DOB or Year of birth
Email*
example@example.com
contact number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*
If recommended by a friend who by?
Would you like to receive our newsletter by Email (usually monthly)?

Yes I am happy to receive newsletters by EmailNo
When is a good time for us to discuss this form and do you prefer a phone call or email response?*
Would you like to receive our newsletter by Email (usually monthly)?*

YesNo
Please list previous or current cosmetic procedures (surgical and non-surgical):*
Please list the cosmetic problems you would like treating / procedures you are interested in: *
Medical and Medication History
Do you suffer from any illnesses we should be aware of when assessing if you can have a treatment: *
Please list all your medication and supplements:
Are you recovering from any medical treatment or operation within the last 12 months?*

YesNO
Please tell us about your problem/ reason for wanting to attend a consultation with us today so that we can customise your appointment to meet your specific needs and concerns.*
Please list the cosmetic problems you would like treating / procedures you are interested in: *
Have you attended a facial consultation in the past?*

YesNo
If yes, did you have any facial treatments?*

YesNo
If no, how long have you been considering treatment for?*
Out of 5, how familiar are you with the different facial treatments available? *

1

2

3

4

5

1 is Worst, 5 is Best
Where 5 is very much and 0 is not at all. How much do you think it affects the following?
Your self-esteem *

1

2

3

4

5

1 is Not at all, 5 is Very Much
Your employment and or social life *

1

2

3

4

5

1 is Not at all, 5 is Very Much
Your personal relationships *

1

2

3

4

5

1 is Not at all, 5 is Very Much
How much does it impact you psychologically*

1

2

3

4

5

1 is Not at all, 5 is Very Much
Does/ will your treatment help you psychologically? ?*

YesNo
Does/ will your treatment help you in any other way?*

YesNoOther
Do you suffer from anxiety symptoms or low mood?*

YesNo
Have you suffered from any psychological problems in the past?*

YesNo
Do you worry a lot about the way you look and wish you could think about it less? *

1

2

3

4

5

1 is Not at all, 5 is Very Much
Does worrying about your appearance make it hard to do your work or be with friends? *

1

2

3

4

5

1 is Not at all, 5 is Very Much
Any other comments:
I confirm I have read and understood the medical questionnaire. I have completed it accurately and discussed all past and present medical conditions with the treating doctor. I am aware that withholding medical information could have a detrimental effect on both my treatment and my health.
I have read the clinics terms and conditions and I am happy to adhere to the 48hr cancellation policy in place.
Please sign
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New Patient Enquiry Form.