Blemish Removal Case Study Application
Complete this form to apply for 40% off treatment offer at Ayumah Asigri Aesthetics in South Croydon. Selection is subject to consultation and clinical suitability.
Please read the following information carefully before completing your application:
Selected participants will receive 40% off the normal treatment price:
• 30 minutes – £90 (usually £150)
• 45 minutes – £120 (usually £200)
• 60 minutes – £150 (usually £250)
A £50 deposit will be required if selected and will be deducted from the treatment price.
Submitting this form does not guarantee selection or treatment. All treatments are subject to consultation, clinical assessment, and suitability.
Case study participants must be willing to have before, treatment, and follow-up photographs taken to document their treatment and results. Selected case study photographs may potentially be submitted for publication within professional aesthetics and social media.
Applicants must be 18 years or over.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email Address
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
Format: 00000000000.
Which type of blemish are you interested in having treated?
*
Dermatosis Papulosa Nigra (DPN)
Skin tags
Cherry angiomas
Seborrhoeic keratoses
Other / unsure
Where is the blemish or blemishes located?
*
Approximately how many blemishes would you like treated?
*
How long have the blemish or blemishes been present?
*
Have you noticed any recent changes in size, shape, colour, texture, bleeding, itching or other symptoms?
*
Yes
No
If yes, please provide further information
Has the blemish been previously assessed or diagnosed by a healthcare professional?
*
Yes
No
Please upload clear photographs of the area you would like treated (required)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Are you able to attend the clinic in South Croydon (CR2 6AL)?
*
Yes
No
Please confirm you understand and agree to the following:
*
I understand that submitting this form does not guarantee selection or treatment.
I understand that all treatments are subject to consultation, clinical assessment and suitability.
I am willing to have before, treatment and follow-up photographs taken to document my treatment and results.
I understand that selected case study photographs may potentially be submitted for publication within professional aesthetics and social media - photographs may be anonymised.
I confirm that I am 18 years or over.
Submit Application
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