Follow & Like usFacebook0Twitter0Pinterest0Please complete this form at least 24 hours prior to your patch test Step 1 of 4 25% Name* First Last Date* Date Format: DD slash MM slash YYYY Address* Street Address City ZIP / Postal Code Email* Enter Email Confirm Email Phone*Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920OccupationWhat areas are you coming for laser treatment on?*Where did you find out about Metro Laser Clinic?*Have you already purchased sessions online?*YesNoHow many sessions did you purchase if yes?Please tell us more if you've had Laser or IPL treatments before enter none if you haven't:* Your Doctor's Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix Last Doctor's Address Street Address Address Line 2 City Please tell us of any medical conditions you have - if none type 'none'*Please tell us of any medications you are currently taking if none type 'none':*Are you pregnant, have a light allergy, history of cancer, auto immune condition, taken anti acne medication (Accutane) in the last six months or have photosensitivityYesNone of these conditionsSome of thesePlease confirm you have watched our info video* Yes I watched it No I haven't Can't access it Have you a deep tan from a vacation in the last 4 weeks on the area to be treated or fake tan?*YesNoYour skin colour/type*1 Very Pale2 Pale with beige tint3 Light Brown/Mediterranean/Light Asian4 Dark Brown/Dark Asian5 Light Black6 BlackWhat happens when you stay too long in the sun?*0 Painful redness, blistering, peeling1 Blistering followed by peeling2 Burns sometimes, followed by peeling3 Rarely burn4 Never burnTo what degree do you get browner?0 Hardly or not at all1 Light colout tan2 Reasonable tan3 Tan easily4 Turn darker brown quicklyPlease tell us if you've had any of these treatments in the last 2 years on the area to be treated [enter 'none' for none] : Glycolic Acid (over the counter) Less10% Retin-A, Differin Renova, Adapin Sunburn Moderate peel Light peel Liposuction Dye laser Accutane (oral) Photoderm (spider veins) Implant surgery, Deep peel, Laser resurfacing , Burns, Surgical scars, Skin graft*Please tell us if you've had aesthetic treatments like botox, chemical peels, microdermabrasion of fillers on the area to be treated [enter 'none' if none]*enter 'none' if nonePlease tell us if you have any of the following and more about the condition: Diabetes, Keloid scarring, Thyroid condition, Melasma, Vitiligo, Pigmentation disorders, Epilepsy or anxiety disorders [Please type 'none' if none]*enter 'none' if noneAre you photosensitive, taking St Johns Wort, have Lupus or on any medications which require you to stay out of the sun?*YesNoNot sure Almost there... Please remember to write down the door entry code we sent you to gain access to the waiting area. You can also purchase plans from us cheaper than anywhere else and we appreciate if you refer friends direct to us. You'll find a printed consent form that you need to initial and sign on arrival. You may reschedule appointments on our online booking system following the links at the bottom of the appointment email. The easiest way to contact us is on the clinic mobile by text 07739 479682 if you're delayed etc. This iframe contains the logic required to handle Ajax powered Gravity Forms.