Where * denotes a required field.
Full Name *
Date of Birth *
Gender * FemaleMale
Email Address *
Phone Number *
Emergency Contact *
Their Phone Number *
Their Relationship to You *
How did you hear about us?---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
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.