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Contour & Lift intake

To tailor your treatment safely and carefully, please complete the intake form below fully and truthfully.

Personal details

Please enter your personal information below.

First name*

Last name*

E-mail*

Gender*

Female

Male

X

Previous treatments

Have you recently had any of the following treatments in the treatment area?

Multiple choice*

Laser hair removal or IPL

Another advanced treatment

None of the above

Which treatment did you have, and when?

Health information

Please answer the questions below fully and truthfully. This allows us to carry out your treatment safely.

Are you regularly exposed to sunlight or tanning beds, or do you use self-tanning products?*

No

Yes

If yes, please provide further details.

Do you have any allergies, such as photosensitivity or histamine reactions?*

No

Yes

If yes, please provide further details.

Do you have permanent make-up or any tattoos? *

No

Yes

If yes, please provide further details.

Are you currently pregnant or breastfeeding? *

No

Yes

If yes, please provide further details.

Do you have an endocrine condition, such as diabetes? *

No

Yes

If yes, please provide further details.

Do you have a neurological condition, such as epilepsy? *

No

Yes

If yes, please provide further details.

Do you have a hormonal imbalance, such as low oestrogen or elevated androgen levels? *

No

Yes

If yes, please provide further details.

Does your skin have any irregularities in texture or pigmentation, such as dark spots? *

No

Yes

If yes, please provide further details.

Do you have any skin conditions or sexually transmitted infections, such as herpes, psoriasis, eczema or keloids?*

No

Yes

If yes, please provide further details.

Do you have a pacemaker, implants, prostheses or any other foreign objects in your body? *

No

Yes

If yes, please provide further details.

Do you have any heart or vascular conditions? *

No

Yes

If yes, please provide further details.

Do you have high blood pressure? *

No

Yes

If yes, please provide further details.

Have you been diagnosed with cancer or any skin tumours?*

No

Yes

If yes, please provide further details.

Do you use any form of contraception?*

No

Yes

If yes, please provide further details.

Do you have an immune system disorder or a weakened immune system? *

No

Yes

If yes, please provide further details.

Do you have any infectious diseases or inflammatory conditions? *

No

Yes

If yes, please provide further details.

Are you currently taking any medication?*

No

Yes

If yes, please provide further details.

Do you have any open wounds?*

No

Yes

If yes, please provide further details.

Do you have varicose veins or any other vascular conditions? *

No

Yes

If yes, please provide further details.

Have you had fillers or Botox? If so, when? *

No

Yes

If yes, please provide further details.

Have you been diagnosed with body dysmorphic disorder (BDD), or do you experience significant distress about your appearance? *

No

Yes

If yes, please provide further details.

Do you have kidney failure? *

No

Yes

If yes, please provide further details.

Your moment

Every guest experiences their treatment differently. We would therefore love to know what would make you feel most comfortable.*

Moments of Silence • I prefer to enjoy my treatment in peace and quiet. We’ll keep conversation to what is necessary for your treatment.

Conversation Welcome • I enjoy a relaxed conversation during my treatment.

Follow the Moment • I prefer to let the moment unfold naturally.

Is there anything else you would like us to know or any questions you would like to ask?

I confirm that I have answered all questions truthfully. I understand that providing incorrect or incomplete information, or failing to follow the treatment guidelines and conditions, may negatively affect the safety and results of my treatment.*

I agree

I agree to the Privacy Policy and Terms and Conditions and consent to my personal data being processed in accordance with applicable law.

Signature*

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Personal care begins long before your first treatment.

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Book an Appointment

Suma laser clinic

Heffen-Dorp 14A

2801 Heffen/Mechelen

T. +32 (0)456 33 12 39

E. info@sumalaserclinic.com

Terms & conditions

Opening hours

By appointment only

Monday 10.00–18.00

Tuesday & Wednesday closed

Thursday–Saturday 10.00–18.00

Sundays & public holidays closed

BE 0763. 388.119

© 2026 Suma laser clinic

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