New Hair Client intake form.

This is your online consultation form, it will take a few minutes to complete. This information given is treated as Confidential. Once submitted one of our team members will be in contact via WhatsApp.
+62 877 6339 0131

Fitzpatrick Scale above is what we use at CleanSlate to identify your skin type. Please identify which option most suits you.

Name

First Name

Last Name

Gender*

Skin Type No. 1 -6 ( from the 'skin type' scale on this page) *

Are you over 18 years old * Y/N

Nationality *

Mobile Phone/ Whatsapp no. ( inc + country code) for us to contact you on *

Email *

Todays Date *

What areas do you want treated with hair removal? *

Please write what day / date you would like to come in as well as am / pm preference *

How did you hear about CleanSlate Laser Clinic?

- google - friend ** please state name - drive-by - instagram - facebook

Please enter any promo discount code or info for discount eligibility

Have you had Laser before? Y/N *

If yes please give details in the large box below including * :

- which country - when was the last treatment - what type of results / regrowth

What is your HAIR COLOUR and DENSITY in each of your planned treatment areas? Please write in the large box below *

BLACK - BROWN- BLONDE- RED FINE- MEDIUM- DENSE

Have you waxed or plucked or used hair removal sprays or creams in the areas to be treated within the last 28 days? Y/N *

Please note the light blonde hair, grey and white hair may be less easy to target and take more treatments with results not guaranteed.

MEDICAL BACKGROUND

Are you currently pregnant, breastfeeding or trying to conceive ? Y/N *

Have you been treated with hormone/ Steroid medication? Y/N *

If yes please explain below

Have you had surgery in the areas to be treated in the last 6 months? * Y/N

If yes please explain below

Have you had significant sun exposure, used self tanning products or been burnt in the last 2 weeks in the area you want treated? * Y/N

Do you have tattoos in the areas you want treated? * Y/N

If you are wanting Facial Laser, have you had cosmetic procedures in the last 2 weeks? * Y/N *

Have you ever been treated with any of the following? If Yes please give name and dates in the big box below. *

Polycystic ovaries Endocrine disorders Thyroid High blood pressure Heart problems or pacemaker Skin Cancer, mole concerns or other cancer Pigmentation Cold Sores Haemophilia Diabetes Epilepsy Anti coagulant Keloids Anti-inflammatory drugs Photo sensitive drugs Roaccutane Allergic / sensitive to light

If you are on any type of IMPLANT Birth Control ONLY, please list all details: (this does not include the pill)

NOTE: Any change to medical history or medications CleanSlate must be notified.

CANCELLATION INFORMATION: FAILURE to arrive for treatments having shaved will result in a charge of RP 150k or a new booking time. CANCELLATION POLICY:* Failure to give CleanSlate Clinic 24 hrs notice before cancellation ( to re-schedule) , failure to follow the pre-care parameters thoroughly and being over 15 mins late (without notifying us) will result in LOSS of Deposit and a new booking time. We do not offer refunds. There is a 2% bank surcharge on credit cards. We apologise in advance .

Full Name (as electronically signed)*

First Name

Last Name