Form & Consent

Mesotherapy & Hydrafacial

Personal Information

Last Name

First name

Date of birth

Center

Sex

woman man

Medical Information

Medical history

Processing in progress

Known allergies

Do you have sensitive skin (a burning sensation after applying an acidic product)?

Are you pregnant?

Yes No

Have you ever had facial injections?

Yes No

If so, in which area(s)?

If so, date of completion:

Are you breastfeeding?

Yes No

Have you recently had semi-permanent makeup or a tattoo done on your face?

Yes No

If so, date of completion:

Have you had any facial treatments or procedures recently (such as microdermabrasion or microneedling)?

If so, which one(s)?

I, the undersigned

certify that the information provided above is accurate and agree to inform the My Laser team of any changes in my health status from this date forward, prior to each mesotherapy or Hydrafacial treatment.

Target issue:

You're getting a tan:

Never Hardly Gradually Easily

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My Laser Casablanca

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My Laser Tanger

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Prices & Locations

My Laser Pricing
Aesthetic Medicine Prices
My Laser Center Casablanca
My Laser Center in Tangier

Contact

Casablanca: +212 5 22 98 37 45

Tangier: +212 5 39 95 26 16

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