Your Full Name (required)
Your Email (required)
Your phone number
Date of birth
Side of the body
Tattoo or Piercing or Laser?
Do you currently suffer from or have you ever suffered from any of the following? If yes please describe the details
Blood pressure problems
Haemophilia/Blood clotting disorders
Blood borne virus e.g. Hepatitis, HIV
Skin Complaints e.g. eczema
Are you prone to fainting attacks?
Do your regular take any blood-thining medicines e.g. aspirin
Do you take any regular prescribed medication?
Could you be pregnant?
How did you find about us?
I declare that the information I have provided on medical history is correct to the best of my knoweldge that I am not currently under influence of drugs or alcohol. I hereby give consent for the procedure detailed above to be carried out by the named operator. I confirm that i have been provided with written information on the potential complication associated with the procedure and i appropriate after care advice for the procedure. I agree that it is my responsibility to read this and follow up the aftercare advice given until the treatment area is healed. Answer Yes or No.