Medical History
Please complete this, it is mandatory prior to receiving any consultation
GP Name *
GP Address *
Do you have any allergies? *
Do you suffer from any medical conditions?  *
Bleeding disorder
Endocrine / hormone issues
Diabetes
Lupus
Pigmentation disorder
Pacemaker / defibrillator
Epilepsy
Lymphatic/Immune system Disorder
History of cold sores
Accutane within 6 months
History of keloid inflammation scarring
History of skin cancer
Dermatological conditions
Photo allergic
Steroids Therapy
High blood pressure
History of cancer
Any abnormal or undiagnosed pigmentation
Laser resurfacing in treatment area within 3 months
Hormone imbalance
Skin conditions
Eczema
Psoriasis
None of the above
Are you currently receiving any medical treatment?  *
Anticoagulants
Antibiotics
Gold medication
Accutane
Retin A
None of the above
Do you have any implanted medical devices or metal plates? *
Are you taking any over the counter medications such as st john warts or vitamins? *
Has the area which will be treated ever had any of the following: (Please tick the relevant box). *
Chemical peels
Botox
Injectable Fillers
Laser or IPL before
None
Have you got any tattoos or permanent make up anywhere on body?  *
Are you pregnant/breastfeeding? *
Have you taken Roaccutane in the last 6 months? *
Do you suffer from cold sores or herpes simplex? *
 Is there anything you think we need to be made aware of before commencing with your treatment? *
Name
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