Laser Consultation Step 1 of 6 - Personal Details0%Personal DetailsName First Last Date of birth Date Format: DD slash MM slash YYYY GenderNon binaryFemaleMalePhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about us?Word Of MouthSearch Engine (i.e Google)MagazineRadioOtherMedical ConsentYour GP's NameYour GP's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency ContactEmergency Contact Name First Last Emergency Phone NumberRelationship To YouMedical AssessmentWhat laser treatment are you interested in?Hair RemovalThread Vein RemovalSkin RejuvenationPigmentation /Age Spot RemovalHave you ever been treated with us before at MySkincare?YesNoDo you have any serious health conditions?YesNoHave you suffered from Epileptic fits?YesNoDo you have any allergies?YesNoGeneral AssessmentPlease tick the appropriate box belowPlease specify your ethnic origin:Your genetic background affects your skin and its response to the laser or IPL.CaucasianMediterraneanAsianMiddle EasternAfrican AmericanNorth AmericanHispanicMixedOtherWhen you sunbathe how does your skin respond?Always burn, never tanUsually burn, sometimes tanNever burn, always tanHave you sunbathed, used sunbeds or developed a tan darker than your usual skin colour in the last 6 weeks?Even from walking around or sitting in the sun.YesNoAre you planning on a holiday soon?YesNoHave you used self-tanning products in the last 3 weeks?YesNoDo you have any implants, tattoos or permanent makeup in/on the area to be treated?YesNoHave you ever used or had Renova or Retin A, Alpha hydroxyl, Glycolic Acid or other cosmetic peels?YesNoHave you ever had Botox or fillers?YesNoHave you ever had laser resurfacing procedures (particularly on the treated area)?YesNoAre you wearing any kind of perfume in the area to be treated?YesNoHave you ever had a skin problem or been under the care of a dermatologist?YesNoAre you using Image/ Alumier /DMK or similar on the area being treated?YesNoAre you on Skin Vitamin A or any Vitamin A product/tablets?YesNoDo you take any medications, drugs or over the counter preparations/remedies?YesNoMedical HistoryTo help give the best possible care, please carefully read and tick all that apply to you from the list below: Cancer / Skin Cancer Acne Roaccutane in last 6 months Psoriasis Rosacea Eczema Vitiligo Port Wine Stain Herpes Cold Sores Shingles Lupus Erythematosus Photosensitive Reactions Cold Sensitivity / Raynaud's Burns / Skin Grafts Keloid Or Overgrown Scars Tattoos / Cosmetic Tattoos Permanent Makeup Do You Smoke Taking Protein Supplements Allergy To Local Anaesthetic High Blood Pressure Heart Disease Implants (Metal Or Other) Pacemaker / Defibrillator Blood Or Bleeding Disorder Blood Transfusion Lymph Gland Disorder Stroke Thrombophlebitis Duodenal / Peptic Ulcer Colitis / Other Intestinal Disease Liver Or Gallbladder Disease Lung Disease Tuberculosis / Pleurisy / Other Urinary Or Bladder Infection Venereal Disease Hepatitis HIV / Aids Frequent Infections Kaposi's Sarcoma Body Dysmorphia Eye Disease / Glaucoma / Cataract Diabetes Neurological Disorder Emotional / Psychiatric Disorder Claustrophobia Seizures / Epileptic Fits Arthritis / Bone Disorder Gold Therapy Endocrine Disorders Hirsutism Polycystic Ovary Syndrome Thyroid Disease Hormone Replacement Precocious Puberty Epidermolysis Bullosa Are You Pregnant? Or Planning A Pregnancy? Are You Breastfeeding? Vaginal Yeast Infection? Other (please specify below)If you have ticked any of the above boxes, please where possible list date diagnosed or treated below:Have you had any prior hospitalizations and surgery in the last 5 years?YesNoFor your consultation what would you prefer?Phone ConsultationEmail ConsultationVideo ConsultationDo you consent to us using your before & after photos?Your identity will be protected.Yes, I AgreeNo, I Do Not AgreeConsent* I hereby declare that the information provided is true and correct to the best of my knowledge.*Consultation Fee Price: 30,00 € Credit Card Card Details Cardholder NameConsent* By using this form you agree with the storage and handling of your data by this website.*Product Name Price: 0,00 € Quantity:
