BioDermal Clinic Registry

BioDermal Clinic

Please read and fill out the complete form
Full Name *

Name Last Name
Birthday

Month Day Year
Month/day/year
Birthday *
Day and Month
Male/Female: *
Email *
example@example.com
Phone Number *

Area Code Phone number
Address

Address

City State/Country

Postal / Zip Code
How did you hear about us? *
Do you suffer or have suffered from: *
If your answer was others please explain in the next question
Others:
Do you drink water regularly? *

No Sometimes Yes
ONLY FOR WOMEN: Are you pregnant?

No Yes
Please select if you use one of the following: *

None Prothesis Pacemaker Contact lenses Birth control pills IUD
What treatment or body products do you use regularly?
Have you visited a dematologist? *

No Yes
Have you had plastic surgery done? *

Yes No
When?
Have you had a facial done before? *

Yes No
When?
Do you have problems with wound healing/scars or keloids? *

Yes No
Do you have metal implant in your body? *

Yes No
Have you had lazer done before? *

Yes No
What type of lazer? *
Have you traveled in the last 14 days? *

Yes No
Have you been in contact with someone confirmed with Covid-19? *

Yes No
Have you had one or more of the Covid-19 symptoms? *

Yes No
Would you like to receive future promotions from Biodermal Clinic? *

Yes No
I relieve all responsibilities to the person who is doing the Beauty Treatment of my person and Biodermal Aesthetic Clinic. I acknowledge that I’m taking my own risk and assume responsibility in any way in the beauty treatment offered here. *

Clear
I relieve all responsibilities to the person who is doing the Beauty Treatment of my person and Biodermal Aesthetic Clinic. I acknowledge that I’m taking my own risk and assume responsibility in any way in the beauty treatment offered here. Please sign in the box.
Signature *

Clear
Offer redeeming code (if it applies)
Present a copy of the code at the reception
Company
Gustazos, oferta del dia, ofertones, others
Date *

Month Day Year
Month/day/year
Should be Empty: