Consultation Form

Please read and answer honestly and carefully the following questions and Submit at the bottom of the page. These form will need to be updated before every treatment.

Thank you. 

To change year, double click

Are you over 18 year old?
Are you on any drugs or medication?
Do you have high or low blood pressure?
Are you diabetic? If yes how is it controlled?
Are you epileptic?
Are you, or do you think you may be pregnant?
Are you breastfeeding?
Have you ever suffered from any blood disorder i.e HIV, Hepatitis?
Have you had Botox in the last 3 weeks?
Do you have any skin disorders or have you ever had any infectious skin disorders?
Have you had a chemical peel in the past 4 months?
Under normal conditions does you skin heal well?
Do you take Roacutane or use Retin A cream?
Do you have any respiratory problems?
Have you had any form of radiotherapy or chemotherapy in the past 12 months?
Do you suffer with Keloid Scars?
Do you take Aspirin?
Do you suffer from dizziness or fainting?
Do you take Warfarin to thin the blood?

Treatment Agreement:

I understand that I have provided an accurate and up to date medical history to the best of my knowledge and failing to do so may affect my general health and have an impact on the final success of my treatment. My technician had fully explained the treatment to me and I understand there are no guarantees on the success or longevity of this treatment and I agree to follow the aftercare instructions given to me.

By ticking Yes, this is a digital Signature that I am confirming that all medical history is accurate, that I understand the the possible risks and accept that I am happy to authorise the treatment to go ahead. 

Thanks for submitting!