LuxTouch IPL Online Consent

Laser/IPL Online Consultation
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Full Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Medical History:

Bleeding disorder, bruise easilyHistory of cold soresHistory of keloid scarringDermalogical conditionsEndocrine/hormone issuePacemaker/defibrilatorHistory of cancerPhotoallergic
List medications taken:
Which Service are you interested in?
List topical products you are currently using (acids, retinol, bleaching cremes etc):
Ethnicity:
Skin Type:

1 - Highly sensitive, always burns, never tans.2 - Very sun sensitive, burns easily, tans minimally.3 - Sun sensitive skin, sometimes burns, slowly tans to light brown.4 - Minimally sun sensitive, burns minimally, always tans to moderate brown.5 - Sun insensitive skin, rarely burns, tans well.6 - Sun insensitive, never burns, deeply pigmented (darker skin tones)
Medical Conditions:
List any allergies:
Last exposed to IV (sun or tanning bed):
Passive Tan:
Should be Empty:

Laser/IPL Online Consultation