Choice a option:
Do you suffer from any disease?YesNo
Are you currently under medical treatment?YesNo
Do you take any medication?YesNo
Are you pregnant or do you want to become pregnant?YesNo
Do you take any type of contraceptive or hormonal substitute?YesNo
Do you have any kind of hormonal disorder?YesNo
Please mark an “X” if you have any of the following::
Please mark an “X” if you have any of the skin conditions:
In which area?
Are you or have you been in treatment for any of the above conditions?YesNo
Please mark with an “X” if you have any of the following:
PorphyriaErythema PoliformusSolar UrticariaLupus
Do you suffer from Epilepsy?YesNo
Do you have a metallic implant, pacemaker, hearing aids ...?YesNo
Do you suffer from any allergies?YesNo
Do you have or have you had cancer or a pre-cancerous lesion?YesNo
Has your skin changed colour after transforming a scar?YesNo
Has any type of self-tanner been applied?YesNo
I have read the my data processing policies, and I am aware of the use of my data.
I read the Q-switched laser treatment policies.
I give my consent to the processing of my data.