Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

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Do you suffer from the following diseases or are you taking any of these medications? (Please select all that apply) *

Hemophilia (blood does not clot easily)

Diabetes mellitus (diabetes)

Hepatitis A, B, C, D, E, F

HIV +

Skin Diseases

Eczema

Autoimmune diseases

Are you prone to herpes?

Infectious diseases / high fever

Epilepsy

Cardiovascular problems

Are you taking medication for blood thinning (anticoagulants)?

Are you pregnant?

Are you taking any medications on daily basis?

Are you taking blood thinners?

Do you have a pacemaker?

Do you have problems with healing of wounds?

Have you consumed drugs or alcohol in the last 24 hours?

Did you in the last 14 days undergo surgery?

Were you exposed to radiation or had any other medical interventions?

Allergies

Other

None

Confirmations *

Please select all

I confirm that I have read and understood the explanation, warranty, top up , treatment notes and further information above.

I received a clear and understandable response to all my questions.

The treatment procedure and post-treatment care was explained to me in detail and I agree with it.

I do not have any further questions and complaints

If I have further questions or concerns, I will contact Anna K Beauty