AMALASER LTD
353 Lordship Lane, London SE22 8JJ
Email: info@amalaserclinic.com
www.amalaserclinic.com/
+(44) 7563 884934
HARMONY MEDICAL FORM
PERSONAL INFORMATION
Gender
*
Please Select
Male
Female
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Full Name
*
First Name
Last Name
Mobile or Landline
*
Format: 00000000000.
E-mail
example@example.com
How did you hear about us?
*
Please Select
Newspaper
Your Website
Treatwell website
Internet
Magazine
Other
Please Specify
*
MEDICAL HISTORY
Contraindications
*
Rows
Yes or No
Are you pregnant?
Yes
No
Are you taking photosensitive medications?
Yes
No
Have you taken Roaccutane in the last 6 months?
Yes
No
Do you have cancer?
Yes
No
Do you have a history of cancer? (In particular skin cancer)
Yes
No
Do you have epilepsy?
Yes
No
Do you have melasma? (applicable if treating facial are)
Yes
No
Do you use sun beds?
Yes
No
Are you sun tanned at present?
Yes
No
Do you have any keloid scars?
Yes
No
Cautions (GP letter advised)
*
Rows
Yes or No
Are you breast-feeding?
Yes
No
Do you suffer from Diabetes?
Yes
No
Do you have any hormonal disorders?
Yes
No
Do you suffer from cold sores or herpes simplex?
Yes
No
Are you having any peels or microdermabrasion on area to be treated?
Yes
No
Have you had Botox or fillers on area to be treated?
Yes
No
Do you have any hyper/hypo pigmentation?
Yes
No
Do you easily sun burn?
Yes
No
Do you have many pigmented lesions on area to be treated?
Yes
No
Do you have excessively dry or sensitive skin?
Yes
No
General medical questions
*
Rows
Yes or No
Do you have any allergies?
Yes
No
Do you suffer from any medical conditions?
Yes
No
Are you currently receiving any medical treatment?
Yes
No
Do you have any implanted medical devices or metal plates?
Yes
No
Are you taking any over the counter medications or vitamins?
Yes
No
Do you have thrombosis?
Yes
No
Do you have any heart or lung problems?
Yes
No
Do you suffer from any autoimmune disorders?
Yes
No
Do you suffer from any mental health condition
Yes
No
Have you had tattoos or permanent make up anywhere on body?
Yes
No
Client signature
*
Print
*
Form Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Please verify that you are human
*
Submit
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