Consultation Form

Choose the Branch Select Victoria Westminster Kensington

Name *

Address

Tel *

Date of Birth

Email address *

Occupation

Hobbies/Sports

Are you pregnant?

Please answer all of the questions, ticking as appropriate:

Please complete this section only IF you intend to receive an eye treatment

Please tick if you have had any of the following:

Has a patch test been completed? No Yes

Date of patch test

Any signs of redness apparent?

Do you wear contact lenses? No Yes

Any other allergies?

Have you had undergone surgery in the last year?

Are you on any medication?

Within the last 6 months have you had any glycolic peels, laser treatment or injectable?

What is the main purpose of your visit?