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Home
Over ons
Behandelingen
Acnetherapie
Acnelan
Camouflagetherapie
Huidanalyse
CoolPeel
Cosmelan
Cryotherapie
Dermamelan intimate
Huidverjonging
Hydrafacial
Laserontharing
Medische peeling
Mesoeclat (Anti Aging)
Mesotherapie
Microneedling / dermapen
Schimmelnagel (Kalknagels)
Skin Detox Treatment
Vaatafwijkingen
Vitamin Brows
Tarieven
Acties
Vergoedingen
Vacature
Blog
Contact
Afspraak maken
Shop
Intake laser
Intake Laser (English)
First name
Surname
Address
Street name + house number
City
Postcode
Date of birth
Email
Phone number
The following questions are about your overall health and medical history. Please tick what applies.
Are you currently healthy?
Yes
No
Kidney or Adrenal Disease?
Yes
No
Allergies, such as photosensitivity or histamine reactions?
Yes
No
Blood or clotting diseases, such as thrombosis?
Yes
No
Endocrinological diseases, such as diabetes?
Yes
No
Heart disease and/or increased/decreased blood pressure?
Yes
No
Skin and/or venereal diseases, such as psoriasis?
Yes
No
Immune diseases, such as a weakened immune system?
Yes
No
Infectious diseases or active inflammation?
Yes
No
Cancer or skin tumors?
Yes
No
Skin lesions associated with vesicles/blisters?
Yes
No
Sensitivity Disorder: Pain, Tingling, Numbness?
Yes
No
Varicose veins or other vascular problems?
Yes
No
Disturbed hormones?
Yes
No
Disrupted wound healing or abnormal scar formation?
Yes
No
Neurological disorders, such as epilepsy?
Yes
No
Do you use or have you used medication?
Yes
No
Do you have a pacemaker, implants or other foreign objects?
Yes
No
Do you use homeopathic remedies or herbal extracts, such as St. John’s wort?
Yes
No
Are you regularly exposed to sunlight, tanning beds or do you use self-tanning creams?
Yes
No
Do you have permanent make up or a tattoo in the area to be treated?
Yes
No
Are you currently undergoing treatments with a doctor, specialist or other skin professional?
Yes
No
Are you pregnant, are you breastfeeding or do you want to become pregnant?
Yes
No
Do you have botox / fillers?
Yes
No
Do you agree that we take before & after photos to assess the progress of your skin and share them on Social Media (without facial recognition)?
Yes
No
I have answered all questions truthfully. It has been emphatically made clear to me that not answering the questions correctly or incompletely and not complying with the conditions can have a negative influence on the result of the treatment.
City
Date
Submit Form
Leyweg 940H
2545 GV Den Haag
070 225 1230
0651673759 (whatsapp)
info@gentleskinclinic.com
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