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Online Consultation Form

GDPR Get rid of unwanted hair permanently using only the most advanced technology. At MediGlow, we use the Cynosure Elite+, the Gold Standard for Laser Hair Removal in 2019.
8

Introduction

We are so excited to get you started on your skin journey! At MediGlow, we are skin experts and like to look at your skin issues from a holistic perspective. We look at factors such as your current skincare routine, diet, stress levels, and water intake as they can have an enormous effect on the skin! Prior to your consultation we need an honest and comprehensive impression of your skin and as such need to gather some information from you. We ask that you fill out and return this pre- consultation form a week prior to your appointment Please ensure the information provided is as recent and up to date as possible We also ask that you take a clear, non-pixelated, bright, front – facing photo and photos of both sides of your face to allow us to assess your skin concerns visually. If you are under the age of 16 (the age of digital consent) we ask that your parent or guardian sign this form on your behalf and if under the age of 18 we ask that you have a parent or guardian present when you sign and also during your consultation.

    Personal Details

    Skin Consultation

    What are your main concerns with your skin?
    • Have you been previously diagnosed with any of the following by a GP
    • What is your skin type?

    How would you describe each area of your face?

    Contraindications

    Diet and lifestyle

    Your information is only used to make your online consultation experience as efficient and valuable as possible. Your data is only viewed by the members of staff who advise you. If at any time you wish us to delete your information please email info@mediglow.ie. View our Privacy Policy for more information.


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