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Laser hair removal intake

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

Personal details

Enter your personal details below

First name*

Last name *

E-mail*

Gender*

Female

Male

X

Previous hair removal methods

Which hair removal methods have you used on the treatment area(s) during the past 6 months?

Multiple choice*

Shaving

Waxing

Hair removal cream

Laser hair removal or IPL

Epilation (tweezers, threading, etc.)

None of the above

Health information

Please answer the questions below fully and truthfully, so we can 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 disorder, 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 pigmentation spots?*

No

Yes

If yes, please provide further details.

Do you have any skin or sexually transmitted conditions, 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 inflammation?*

No

Yes

If yes, please provide further details.

Do you currently take 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.

Do you have kidney failure?*

No

Yes

If yes, please provide further details.

Your moment

Every guest experiences a treatment differently. That’s why we’d love to know what feels most comfortable for you.*

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 and completely. I understand that providing incorrect or incomplete information, or failing to follow the treatment guidelines, may affect the outcome 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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