Laser Skin Consultation 1Step One2Step Two3Step Three4Step Four YOUR NAME YOUR DATE OF BIRTH YOUR EMAIL ADDRESS YOUR PHONE NUMBER DO YOU USE SUNSCREEN? YES NO IF YES PLEASE STATE WHICH SPF BELOW:WHEN YOU SUBATHE, HOW DOES YOUR SKIN RESPOND? ALWAYS BURN, NEVER TAN USUALLY BURN TAN WITH DIFFICULTY SOMETIMES BURN, TAN ABOUT AVERAGE ALMOST NEVER BURN, TAN VERY EASILY RARELY BURN, TAN EASILY NEVER BURN, ALWAYS TAN DO YOU SUFFER OR HAVE SUFFERED FROM ANY OF THESE MEDICAL ONDITIONS? ACNE ARTHRITIS ANY AUTOIMMUNE DISEASE BLOOD DISORDER CANCER (OR RADIATION THERAPY) DIABETES HERPES (OR COLD SORES) HIRSUTISM VITILIGO KIDNEY DISEASE MELANOMA PORT WINE STAIN PSORIASIS HAVE A PACEMAKER FITTED SHINGLES SKIN PIGMENTATION STERIOD OR HORMONAL THERAPY HORMONAL IMBALANCES POLYCYSTIC OVARIAN SYNDROM KELOID SCARS / OTHR SCARS MELASMA PIGMENTATION ARE YOU CURRENTLY BEING TREATED FOR ANY CONDITION NOT LISTED? YES NO IF YES PLEASE PROVIDE DETAILS BELOW:DO YOU SUFFER FROM KELIOD SCARRING? YES NO ARE YOU TAKING ANY PRESCRIPTIVE MEDICATION INCLUDING TOPICAL CREAMS? YES NO IF YES PLEASE STATE THE MEDICATION BELOW:HAVE YOU TAKEN ANY ANTIBIOTICS IN THE LAST 14 DAYS? YES NO IF YES PLEASE STATE THE MEDICATION BELOW:HAVE YOU USED ROACCUTANE BEFORE? YES NO IF YES WHEN DID YOU FINISH TAKING IT?ARE YOU PREGNANT, TRYING TO BECOME PREGNANT OR BREASTFEEDING? NO YES I AM CURRENTLY BREASTFEEDING I AM TRYING TO BECOME PREGNANT DO YOU HAVE ANY ALLERGIES? (e.g ASPIRIN) YES NO IF YES PLEASE SPECIFY:DO YOU SUFFER FROM ANY AUTOIMMUNE DISEASES? YES NO IF YES PLEASE SPECIFY:HAVE YOU EVER USED (OR ARE CURRENTLY USING) RETINOL OR GLYCOLIC ACID? YES NO IF YES PLEASE GIVE DETAILSDO YOU SUNBATHE OR USE SELF TANNING PRODUCTS OR USE TANNING BEDS? YES NO IF YES PLEASE GIVE DETAILSARE THERE ANY HEALTH ISSUES WE SHOULD KNOW ABOUT? YES NO IF YES PLEASE GIVE DETAILSDO YOU HAVE A PACEMAKER? YES NO HAVE YOU EVER HAD A CHEMICAL PEEL? YES NO IF YES PLEASE DESCRIBE YOUR TREATMENT:HAVE YOU EVER HAD ANY LASER TREATMENTS? YES NO IF YES PLEASE DESCRIBE YOUR TREATMENT:DO YOU HAVE ANY DENTAL OR ACRYLIC IMPLANTS, CROWNS OR BRIDGEWORK? YES NO IF YES PLEASE GIVE DETAILS:DO YOU HAVE ANY TATOOS OR PERMANENT MAKEUP IN THE AREA TO BE TREATED? YES NO IF YES PLEASE GIVE DETAILS:HAVE YOU HAD FILLER OR BOTOX / DYSPORT INJECTIONS IN THE AREA TO BE TREATED? YES NO IF YES PLEASE GIVE DETAILS:HAVE YOU EVER BEEN TREATED BY AN ENDOCRINOLOGIST (HORMONE IMBALANCE)? YES NO IF YES PLEASE GIVE DETAILS:HAVE YOU EVER HAD GOLD THERAPY (USED FOR RHEUMATOID ARTHRITIS)? YES NO IF YES PLEASE GIVE DETAILS:DO YOU HAVE ANY PARTICULAR SKIN SENSITIVITIES? YES NO IF YES PLEASE GIVE DETAILS: WHAT PRODUCTS ARE YOU CURRENTLY USING ON YOUR SKIN?IS THERE ANY ADDITIONAL INFORMATION YOU WOULD LIKE TO PROVIDE?DO WE HAVE PERMISSION TO USE YOUR PICTURES FOR MARKETING PURPOSES? YES NO HAVE YOU BEEN DIAGNOSED WITH OR CARED FOR ANYONE THAT HAS BEEN DIAGNOSED WITH COVID-19 IN THE LAST 2 WEEKS? YES NO IF YES PLEASE PROVIDE DETAILSHAVE YOU HAD ANY SYMPTOMS OF COVID-19 (FOR EXAMPLE A COUGH, FEVER, CHILLS, SHORTNESS OF BREATH OR LOSS OF TASTE OR SMELL) OR BEEN IN CLOSE CONTACT WITH ANYONE DISPLAYING THESE SYMPTOMS IN THE LAST 2 WEEKS? YES NO HAVE YOU HAD A COVID VACCINATION IN THE LAST 2 WEEKS? YES NO IF YES PLEASE PROVIDE DETAILSARE YOU CURRENTLY SUFFERING FROM LONG COVID? YES NO PLEASE PROVIDE THE NAME AND CONTACT DETAILS FOR YOUR NEXT OF KIN PLEASE PROVIDE THE NAME AND CONTACT DETAILS OF YOUR GP WOULD YOU LIKE TO RECEIVE A COMPLIMENTARY PERSONALISED HOME SKINCARE PLAN? YES NO PLEASE TICK TO SAY YOU HAVE READ & AGREE TO OUR TERMS & CONDITIONS:* I AGREEI agree to my information being store used by the Sanctuary to provide me with a personalised skin analysis. Your details are safe with us we will never share any of your personal details with any 3rd parties. For full terms and conditions of using our website click here.
