Laser Tattoo Removal Consultation Form

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Client Name: *

Address: *

Postcode: *

Tel Home:

Tel Mobile: *

E-mail Address: *

Age:

D.O.B *

GP Name & Surgery: *

GP Contact No: *

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MEDICAL HISTORY

Do you have a history of, or suffer from any of the following?

General Health Problems *

e.g. Diabetes / Asthma / Liver / Kidney disease

Please specify / give details:

Blood disorders / Haemophilia / HIV / Hepatitis / Septicaemia *

Please specify / give details:

Coronary / Pacemaker / Blood pressure conditions *

Please specify / give details:

History of bleeding/coagulation or clotting disorders / use of anti-coagulants *

Please specify / give details:

Depression or any other mental health disorder *

Please specify / give details:

Epilepsy *

Please specify / give details:

Cancer / skin cancer *

Please specify / give details:

Any skin disease *

Please specify / give details:

Skin disorder / psoriasis / eczema / vitiligo / dermatitis / melasma / inflammatory skin condition *

Please specify / give details:

Skin pigmentary conditions *

e.g. Hyperpigmentation / Moles / Pigmented naevi

Please specify / give details:

Herpes/cold sores in treatment area *

Please specify / give details:

Are you pregnant, planning a pregnancy or breast feeding? *

Do you use the contraceptive pill or other hormone therapy or fertility drugs? *

Please specify / give details:

Do you suffer from Polycystic ovarian syndrome or any other hormonal imbalance? *

Please specify / give details:

Do you suffer from any thyroid condition? *

Please specify / give details:

Do you have any allergies/intolerances? *

Please specify / give details:

ANY ADDITIONAL NOTES/COMMENTS ON MEDICAL HISTORY:

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MEDICATION

To ensure that you have no adverse reaction to laser treatments it is important for us to know if you are taking any medication. Some medications can photo sensitize the skin and we may need to obtain your doctors consent before we can proceed with laser treatment.

Are you taking any medication? *

Please specify / give details:

Are you currently, or have you used Roaccutane, Isotretinoin’s or Retin A in the last 6 months? *

Please specify / give details:

Have you taken antihistamines, antibiotics, cold remedies or pain killers in the past 2 days? *

Please specify / give details:

Have you taken St John’s wort in the last 3 months? *

Please specify / give details:

Are you taking any herbal or homeopathic remedies that may photosensitize your skin? *

Please specify / give details:

Have you taken any anti-coagulants, warfarin/herpin or gold therapy in past 3 months? *

Please specify / give details:

ANY ADDITIONAL NOTES/COMMENTS ON MEDICATIONS:

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PREVIOUS SKIN TREATMENT HISTORY

Are you currently, or have you ever used Glycolic or retinol products *

Are you currently, or have you ever received laser treatment? *

Are you currently, or have you ever received Microdermabrasion? *

Have you had any direct sun or sunbed exposure in the past 4 weeks? *

Do you use self-tan products? *

I confirm that all the information I have given is accurate to the best of my knowledge and I will ensure that I advise my practitioner of any changes.

Patient Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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Covid-19 Guidance

Appointment Guidance

- Please only attend at your appointment time

- Please ensure you are on time - if you are late this may result in your appointment being cancelled

- Please attend your appointment unaccompanied

- Please limit the personal possessions you bring with you

- Hand sanitiser will be provided upon arrival and will be available throughout your appointment

- Please wear a face covering to enter and walk around the salon/clinic

- We encourage contactless/card payments where possible

- If you experience Covid-19 symptoms after your appointment please contact us immediately

Have you, or anyone in your household, had any of the following symptoms in the last 14 days: dry cough, fever, high temperature, shortness of breath, loss of sense of taste or smell, sore throat? *

Please DO NOT attend your appointment. Please contact us to cancel / reschedule.

Have you, or anyone in your household, been in contact with any confirmed COVID-19 positive patients? *

Please DO NOT attend your appointment. Please contact us to cancel / reschedule.

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