Are you currently undergoing any medical investigations by a doctor or hospital specialist? *

Pregnant or planning pregnancy *

Suntanned/using sunbeams / fake tan*

Skin pigmentation disorder (e.g Melasma, Vitiligo*

History of cancer (or chemo/radio therapy)*

Diabetes *

Epliepsy *

Lymphatic/immune system disorder *

Lupus *

Communicable diseases (Hepatitis/HIV)*

Photosensitive conditions*

Depression/Anxiety*

High blood pressure*

Anaemia*

History of keloid formation/scarring*

Haemophilia*

Regular smoker *

St John’s Wort*

Anti coagulants*

Oral or Topical retinoids (e.g Roaccutane or Retin A)*

Amoiderone*

Gold medications *

Oral or topical steroids*

Minocycline*

Are you currently recovering from any major medical treatment or photodynamic therapy (PDT) within the last 6 months?*

Has the area for treatment ever had any of the following?*

Do you have any allergies to latex?*

Have you ever suffered from any skin disorders or disease? *

Please indicate how your skin responds to midday summer sun exposure with NO sunscreen*

Do you currently have a real or fake tan?*

Have you had any sun exposure or used a sun bed in the last 4 weeks?*

Where did you hear about the clinic?*

Declaration : by signing this medical form. I declare that the information and statements given on this form are true and complete to the best of my knowledge. I am aware that any false statements may affect my treatment outcomes and after care.

Date of Signature*