Electrolysis & Blemish Removal Consultation Form

Client Name: *

Date: *

Date of Birth: *

Email: *

Would you like to receive special offers via email? *

Yes No

Address: *

Postcode: *

Contact Number: *

Occupation

How did you hear about us?

Are you currently under medical care?

Yes No

If Yes, please specify

Are you currently taking any medication?

Yes No

If Yes, please specify

Please tick all that apply

Area to be treated for HAIR REMOVAL CLIENTS

Area to be treated for BLEMISH REMOVAL CLIENTS

Any previous treatments?

I understand that In-DERM Skin Clinic operates a strict 24 hour cancellation policy. Late cancellations will incur 50% treatment fee and no-shows will incur 100% fee.

I declare I have disclosed all necessary information in order that treatment may be carried out safely.

I understand there is a healing process following treatement and I must adhere to the aftercare advice. Where appropriate a "test patch" will be performed to ascertain skin reaction and I understand (irrespective of whether this is performed) there is no guarantee of treatment success.

I understand that there is a small risk that minor pigmentstion/ tissue damage following treatment may occur which may or may not prove permanent.

I consent to photos being taken for monitoring progress of the treatement.

Patient: *

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.