Request form

NOTE: Submitting this form does not confirm your consult or booking. You will receieve a phone call once you have submitted your request to confirm a time and date.

PERSONAL INFORMATION

1. Which treatment and what areas (e.g. legs) are you interested in having?

2. What are your goals and expectations of the treatment?

3. Have you used any of the following in the past 30 days?

NoneSun bedsSelf-tanning creamTanning in the sun

4. When was your last sun holiday, and when is your next sun holiday?

Medical Information

5. Do any of the following apply to you? Please tick those that apply.

Heart DiseaseAnti-coagulantsPolycystic ovarian syndromeHirsutismLiver / Kidney diseaseDiabetesAidsPregnantAcneCancer (or radiation/chemotherapy)Herpes (or cold sores)Lupus DiseaseClotting disordersEpilepsyPsoriasisBreast Feeding

6. Specify a medical condition that is not listed above.

7. List any medication that you are taking.

8. If you have any implants, list the area.

9. Do you have any skin sensitivities or allergies?

NoYes

10. Have you had any major surgery performed in the last 3 months?

NoYes

The terms of service is a legal agreement between you and Laika Clinics Pty Ltd. By checking this box, you agree to be legally bound by the terms, conditions and disclaimers and you acknowledge and agree that you have read and understood the Terms & Services.

Latest Terms & Conditions can be found by clicking HERE.