Enquiry Form

BSL Clinic Enquiry form and photo submission

Please use this form to submit your BEFORE treatment photo for the BSL Clinic’s administration. The selected photo will be shared with our experience experts to provide their professional treatment.

If you have more than one set of photos to submit, use this form to present the first set (all views), then use your back button to reload the structure for your next submission.

Once your submission is reviewed, we will notify you if your photo has been selected. If you have any questions, please email [email protected].

What is your full name?*

What is the best email we can reach you?*

What is the best phone number we can reach you?*

For tourists: what hotel/service apartment do you stay in in Bangkok?*

Travel plan: length of stay:

From to

Your skin problems: *

Treatment that you look for:*

Any previous treatment:*

Photo Consent Release*
I consent to and authorize BSL Clinic, its affiliates, agents, representatives, and all persons or entities acting with its permission or upon its authority (collectively "BSL Clinic") to use my photographs and digital images (the "Material") being taken to evaluate treatment effectiveness, for medical education, training, professional publications or sales purposes. No photographs or digital images revealing my identity will be used without my written consent. If my identity is not shown, these photographs and digital images may be used, shared, and displayed publicly without my permission. I further grant BSL Clinic the right to incorporate and use the Material in the video and print ads. Still, photographs, catalogs, packaging, package inserts, website, and all other media (the "Advertising") are used to reproduce, exhibit, broadcast, transmit and distribute Advertising containing the Material. I, at this moment, assign to BSL Clinic all of my rights, title, and interest in and to the Material and any rights, including copyrights that may result from the use of any Material in any Advertising. I waive any right to inspect or approve the Advertising incorporating the Material and the services to which it may be applied. I HAVE READ THE PRECEDING RELEASE AND FULLY UNDERSTAND IT, AND AGREE TO THE TERMS OUTLINED. By checking this box, I agree to the terms of this consent statement.

I agree to the terms of this consent statement.

File Upload* Attached is a photo of the area that wants the evaluation treatment.
Please upload 1. Before Photo(s) - highest resolution possible

Send me a copy of my responses

BSL Clinic Enquiry form and photo submission

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