First Name

Last Name

Email *

Phone *

Which body areas would you like to have treated with laser hair removal? Check all that apply *

Underarms

Upper Lip

Chin

Sideburns

Full Face

Full Face and Neck

Half Arms

Stomach

Lower Back

Upper Back

Full Arms

Full Back

Lower Legs

Upper Legs

Full Legs

Bikini

Full Brazilian

Do you have any skin conditions on the treatment area? (select if all apply) *

Rosacea

Acne

Acne Scars

Pigmentation/ or Dark spots

Melasma

Eczema

None

Do you have any Allergies? If yes, please specify, otherwise write NO *

Have you got any medical esthetic treatments in the last month? If YES, when was it and what treatment, otherwise write NO *

Medical History –Inform your Aesthetician prior to treatment if you have any of the following conditions that may make you unsuitable for DiolazXl Laser Hair Removal treatment. *

Pregnancy or nursing

Under 18 years of age

Pacemaker or internal defibrillator or any electronic Implant such as glucose monitor

Permanent implant in the treated area such as metal plates and screws, silicone implants or an injected chemical substance

Current or history of cancer, especially skin cancer, or pre-malignant moles

Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications

Severe concurrent conditions such as cardiac disorders, epilepsy, uncontrolled hypertension, and liver or kidney diseases

A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area

Any active condition in the treatment area, such as sores, psoriasis, eczema and rash as well as excessively/freshly tanned skin

History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin

Tattoos, permanent make-up, pigmented lesions (to be kept)

Poorly controlled endocrine disorders, such as diabetes or thyroid dysfunction

Any surgical, invasive, ablative procedure in the treatment area in the last 3 months or before complete healing

Superficial injection of biological fillers in the last 6 months, or Botox in the last 2 weeks

Use of Isotretinoin (Accutane) within 6 months prior to treatment

Any medical condition that might impair skin healing.

None