Full Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
What Communication would you like to receive from us
Appointment Reminders
Promotion and Offers
Newsletter
How would you like to receive them?
Phone
Mobile/SMS
Email
Post
Doctor's name and address
*
Previous treatments and reason for treatment.
*
Heart Condition / Pacemaker
*
Yes
No
Severe circulatory disorders / DVT
*
Yes
No
Diabetes
*
Yes
No
Skin Disorder
*
Yes
No
Kidney Problems
*
Yes
No
Swelling/oedema
*
Yes
No
Haemophilia
*
Yes
No
Cancer
*
Yes
No
Limitation of body movement/arthritis
*
Yes
No
Are you pregnant
*
Yes
No
Epilepsy
*
Yes
No
Prone to keloid scarring
*
Yes
No
Hormone imbalance
*
Yes
No
Stroke
*
Yes
No
Claustrophobia
*
Yes
No
Hepatitis
*
Yes
No
Metal plates/pins/piercings
*
Yes
No
Recent scar tissue/surgery
*
Yes
No
Respitaratory problems
*
Yes
No
Allergies
*
Yes
No
High/low blood pressure
*
Yes
No
Oprations within 6 months
*
Yes
No
Any other medical conditions/ailments
*
Yes
No
Please specify
Steroids
*
Yes
No
Other medication
*
Yes
No
Ultra violet exposure
*
Yes
No
Retinol or Roaccutane
*
Yes
No
Products containing fruit acids
*
Yes
No
Microdermabrasion
*
Yes
No
Laser/IPL
*
Yes
No
Any other medications
*
Yes
No
Decleration
*
I declare that the above information I have given concerning my health is correct.
Signature
*
Submit
Submit
Should be Empty: