CONSULTATION FORM

PERSONAL INFORMATION

Your personal information and privacy will be protected. Our privacy policy is available here.

1. FIRST AND LAST NAME

2. MOBILE PHONE

3. STREET ADDRESS

CITY

POSTAL CODE

4. EMAIL

Email and Privacy

By giving my email I agree to receive monthly promos and newsletters from Dermal Laser Centre. Your email address will not be shared.

5. BIRTHDATE

7. CANCELLATION POLICY

I understand that there will be a $50 charge for missed appointments of 1 hour or less, and a $100 charge per hour for appointments that have not been cancelled 24 hours in advance

YOUR SKINCARE GOALS

1. WHAT IS THE MAIN REASON FOR YOUR VISIT?

2. PLEASE SELECT ALL THE TREATMENTS YOU ARE INTERESTED IN

BODY IMPROVEMENTS

3. WHICH THREE STATEMENTS BEST REFLECT HOW YOU WOULD LIKE TO LOOK?

OTHER GOALS

4. AREAS OF CONCERN

YOUR HEALTH

1. PLEASE SELECT ANY CONDITIONS WHICH MAY APPLY TO YOU

OTHER CONDITIONS

I have selected and listed all health conditions that apply to me *

2. ARE YOU CURRENTLY UNDERGOING ANY SKIN TREATMENTS SUCH AS LASER, IPL, CHEMICAL PEELS, ETC?

Yes No

IF YES, PLEASE DESCRIBE YOUR SKIN TREATMENT

3. HAVE YOU RECENTLY HAD BOTOX OR DERMAL FILLER TREATMENT?

Yes No

IF YES, PLEASE DESCRIBE YOUR BOTOX/DERMAL FILLER TREATMENT TREATMENT

4. PREVIOUS COSMETIC PROCEDURES?

5. ARE YOU CURRENTLY TAKING ANY MEDICATIONS?

Yes No

IF YES, PLEASE LIST ANY MEDICATIONS YOU ARE TAKING

6. HAVE YOU TAKEN ORAL ACNE MEDICATIONS WITHIN THE LAST YEAR (EG ACCUTANE, TETRACYCLINE, ROACCUTANE, ETC)?

Yes No

IF YES, PLEASE LIST ALL ACNE MEDICATION

7. PLEASE LIST ALL DRUG ALLERGIES

8. PLEASE LIST ALL OTHER ALLERGIES (SKIN PRODUCTS, LATEX, VINYL, METAL, ADHESIVE, ETC)

9. HAVE YOU BEEN EXPOSED TO THE SUN, A TANNING BED, OR SELF-TANNING CREAMS IN THE PAST 2 MONTHS?

Yes No

IF YES, PLEASE PROVIDE TANNING DETAILS

10. IN THE SUN, WITHOUT SUNSCREEN, DO YOU:

Always burn/never tan Usually burn/then may tan Sometimes burn/tan gold brown Rarely burn/tan easily

11. ETHNIC BACKGROUND, GOING BACK 2-3 GENERATIONS

CONTACT US

SKIN TREATMENT CLINIC
VANCOUVER

Medi Spa Vancouver | Beauty Spa Vancouver | Skin Treatment Physicians Vancouver | Skincare Vancouver

Dermal Laser Centre
803 Davie Street
Vancouver, BC V6Z 1B7
SMS Davie: 604-256-7944
Tel: 604-638-7546

Dermal Fillers & Botox Vancouver
Laser Hair Removal Vancouver
CoolSculpting Vancouver
Microneedling Vancouver
Anti-Aging Vancouver
Fat Removal Vancouver
Acne Treatment Vancouver
Belkyra Treatment Vancouver
Chemical Peel & Microdermabrasion Vancouver
Hair Treatment Vancouver
Venus Versa & Venus Viva Vancouver
IPL Treatment Vancouver
Ultherapy Vancouver
Beauty Booster Vancouver

SKIN TREATMENT CLINIC
NORTH VANCOUVER

Medi Spa North Vancouver | Beauty Spa North Vancouver | Skin Treatment Physicians North Vancouver | Skincare North Vancouver

Dermapure Lower Lonsdale
121 Esplanade West
North Vancouver, BC V7M 0G7
SMS North Vancouver: 604-210-8312
Tel: 604-982-3223

Dermal Fillers & Botox North Vancouver
Laser Hair Removal North Vancouver
CoolSculpting North Vancouver
Microneedling North Vancouver
Anti-Aging North North Vancouver
Fat Removal North Vancouver
Acne Treatment North Vancouver
Belkyra Treatment North Vancouver
Chemical Peel & Microdermabrasion North Vancouver
Hair Treatment North Vancouver
Venus Versa & Venus Viva North Vancouver
IPL Treatment North Vancouver
Ultherapy North Vancouver
Beauty Booster North Vancouver

Botox, Vancouver, North Vancouver Skincare Clinic | Privacy Policy | Sitemap

CONSULTATION FORM

PERSONAL INFORMATION

YOUR SKINCARE GOALS

YOUR HEALTH

CONTACT US

Botox & Dermal Fillers

Belkyra

Ultherapy

Coolsculpting

Laser Hair Removal

Beauty Booster

Venus Viva

Medical Microneedling

Skin Rejuvenation

SKIN TREATMENT CLINIC
VANCOUVER

SKIN TREATMENT CLINIC
NORTH VANCOUVER

CONSULTATION FORM

PERSONAL INFORMATION

YOUR SKINCARE GOALS

YOUR HEALTH

CONTACT US

Botox & Dermal Fillers

Belkyra

Ultherapy

Coolsculpting

Laser Hair Removal

Beauty Booster

Venus Viva

Medical Microneedling

Skin Rejuvenation

SKIN TREATMENT CLINICVANCOUVER

SKIN TREATMENT CLINICNORTH VANCOUVER

SKIN TREATMENT CLINIC
VANCOUVER

SKIN TREATMENT CLINIC
NORTH VANCOUVER