Please fill in and submit this form at your earliest convenience. While laser treatment is a safe and well-researched process, we need these details so that we can ensure the safest and best possible outcomes for you.

Name

First Name

Last Name

Phone

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Please list any medical conditions, allergies and illnesses that you have.

Please list all medications that you've taken in the last 6 months.

Please provide details of any exposure to sun beds, tanning products and direct sunlight in the last two weeks.

Please provide details of any use of chemical peels, vitamin A cream, alpha hydroxy acids, laser resurfacing or cortisones in the last 6 weeks.