new-test FormWizard_v4 #London Aesthetics Registration Form Personal Information First Name: Last Name: * Date of Birth: City: LahoreFaislabadIslamabad Source: FacebookWeb FormOther Your Email: * Phone Number: * Address: Gender: MaleFemaleTransgender Are you an existing customer? NOYES Procedures (Please tick the procedures you are interested to discuss with Laser / Skin Doctor) Unwanted Hair Removal With Laser Aging Skin/ Face Lifting Acne Treatment Sagging Skin at Face or Tummy Acne Scars Weight Loss Pigmentation on Face/Freckies Moles Body Fats/Cellulite Keloids/ Hypertrophic Scars Stretch Marks Skin Disease Skin Whitening Treatment Hair Loss/ Hair Fall Botox/Derma Fillers Prp Treatment/Carboxy Therapy Pigmentation on Face/Freckies Moles Cosmetic Surgery Male Health Female Health Pain Management Others I NEED Skin Consultation Laser Procedure Hair Consultation Weight Loss Consultation Information Are you currently taking any medication? (Prescribed/Over-Counter/Herbal) If Yes Please List Do you have any general or medical allergies? No Any If yes please select Are you allergic to pencilin? Are you allergic to latex? Are you allergic to plasters? Are you allergic to Iodine? Other History Smoking Alcohol Pregnancy BreastFeeding Past Surgery History Past serious illness Do You Have Now or Have Ever Had Any of the Disease / Condition Listed Below? Heart Disease Lungs Hyper Tension DM Diabetes Bleeding Disorder Epilepsy Thyroid Kidney Fainting Do You Ever Had Any Previous Medical(Non-Surgical) Cosmetic Treatments? Botox for wrinkles Botox Dermal Filler Chemical Peels Pigmentation Treatment Laser Skin Resurfacing Acne Scar Treatment Laser Hair Removal Sclerotherapy for Leg Veins Fat Reduction / Weight Loss Lipo Section / Tummy Tuck Other Agreement I understand that I must inform Doctor or Clinic if there are any changes to my personal or medical details between treatments. I agree that I have the answered above questions honestly and to do the best of my knowledge.