Remember Me
Where * denotes a required field.
Full Name *
Date of Birth *
Gender * FemaleMale
Email Address *
Phone Number *
Address *
Emergency Contact *
Their Phone Number *
Their Relationship to You *
How did you hear about us?—Please choose an option—Word of MouthSearch EngineNewspaperRadioTVFlyerOther
How did you hear about us?
Do you have a history of the following medical conditions? * PregnancyBreastfeedingRecent surgery (in the last 12 months)Type 1 DiabetesType 2 DiabetesHeart conditions/pacemakerHigh/Low blood pressureMetal plates/PinsAutoimmune disorder (HIV, Lupus)Hormonal imbalanceEpilepsyRecent cancer treatmentThrombosisHyperthyroidHypothyroidMuscle or joint disordersEye infections/conditionsAlopeciaTrichotillomania (compulsive hair pulling)Nail infections/fungal (athletes foot)Back problemsVaricose veinsAsthma/ breathing difficultyNone of the above
Additional Notes:
In the past 3 months have you been prescribed any the following medications? * IsotretinoinAntibioticsPhotosensitive medicationsSt. Johns wortMuscle relaxant medicationsSteroidsWarfarinAccutane (within 6 months)Other medication (please note below)None of the above
Do you have allergies to any of the following? * AspirinPollen (hey fever)Heightened allergies to food/ productsStainless steelLatexOther (Please note below)None of the above
In the past 3 months have you used any of the following topical medication/treatments? * Retinol/Vitamin AHydrocortisoneHydro-quinoneAHAS/BHASNone of the above
In the past 3 months have you had any the following? * Anti-wrinkle injections/BotoxDermal fillersRecent sunbeds/sun exposureLaser/IPLSkin peelsSkinPen microneedling/dermal needlingNone of the above
Please tick the appropriate box below
Do you smoke? * YesNo
Do you drink alcohol? * YesNo
Do you regularly have sunbeds/ sun exposure? * YesNo
Do you primarily work? * IndoorsOutdoors
Do you wear contact lens? * YesNo
Do you consent to Before & After images to be taken and possibly used by the clinic for social media purposes? (Your identity will not be revealed) * Yes, I agreeNo, I do not agree
I confirm the information given is correct and that I will update Luminess Skin and Laser Clinic with any relevant changes to medications, conditions and allergies when necessary.
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