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?*
Your skin problems: * Skin breakouts Laser for Freckle, dark spots Moles, Skin Tags, Skin Bumps Melasma Sensitive skin Skin rash Blemish & Scar removal Birthmark Skin Lightening & Color Correction Facial Revival & Nourishment Laser Skin Resurfacing Line & wrinkle correction Skin texture correction Skin Rejuvenation Skin Pore Tightening Darken Lip Eyes issue: Dark eye circle, wrinkles. hollowness Underarm issue: brightening, smoothing Hair Removal Hyperhidrosis(excessive sweating) Excessive sweating/body odor Varicose vein/spider vein Tattoo removal Facial Design & Age-Defying Treatment Anti-Wrinkle injections Brow & Eyelid lifting Filler Program Face Lifting Facial Line Correction & Age Defying Treatment V-shape face Skin tightening Submental & Neck Lifting /Tightening Anti-Cellulite treatment Body contouring & Weight Loss Stretch Mark Calf reduction & Reshaping Hair thinning, Baldness & Hair Loss Dandruff Hair Regrowth Therapy CO2 laser Fraxel:Dual Laser Program Fractite Pro Face&Neck Lifting Fractora Program Forma Program Forma Plus Program Morpheus8 Program (Microneedling RF) Healite II Program PicoWay Laser Program PicoWay Zoom 1064 532 Program PicoWay Fusion 532 Program PicoWay Resolve 1064 532 Program PicoWay 730 Program Revlite Laser Program Lutronic Spectra Gold Program Q-switch pigmented laser IPL Pigmented & Photorejuvenation B&C Vascular laser Ulthera Program: Non-invasive face lift Ultraformer III Program Ultrashape Power Program Skin tight plus program Body FX Program Liposonix Program Laser Hair Removal (Cutera Program) Laser Tattoo Removal (PicoWay 1064 532 Program) Sclerotherapy(Correction of veins, spider) Scar Subcision Vascular laser (Cutera Program) Mesotherapy Program Other please specify
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.
(10 mb) (10 mb) (5 mb)
