Charlie Locks Consultation Cryo Solihull Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Phone(Required)GP Details(Required) Occupation(Required) Do you have any of the following?(Required) Discolouration Acne scarring Uneven skin texture Fine lines Wrinkles Enlarged Pores Loss of facial contours Dilated capillaries Lax or sagging skin Acne/Breakouts Redness Dark under eye circles Cancer or have had cancer* None of the above If you have answered yes to any of the above - please provide further information and where on your face do you have the above? How would you best describe your skin type?(Required) Normal Dry Combination - Oily T zone Combination - Dry and normal Oily Do you have a history of acne?(Required) Yes No If yes how often do you get a flare up? Do you use Retin A? Please note this ingredient is also present in some creams and moisturisers too - This ingredient is contra indicated for facials so we are unable to provide this service.(Required) Yes No Have you ever used Accutane? Please note this ingredient is also present in some creams and moisturisers too? This ingredient is contra indicated for facials so we are unable to provide this service.(Required) Yes No Do you use Glycolic Acid products? Please note this ingredient is also present in some creams and moisturisers too? This ingredient is contra indicated for facials so we are unable to provide this service.(Required) Yes No Have you ever had an acid peel? You must not have this treatment until 4 weeks after your peel.(Required) Yes No Are you claustrophobic?(Required) Yes No Do you wear contact lenses? Please note these will need to be removed prior to your treatment(Required) Yes No Do you sunbathe or use tanning beds? Please be aware if you have any tan on your face this will be removed by the products we use(Required) Yes No Please list any allergies: Please list any medical or health conditions you have: please put N/A if none(Required) Are you pregnant or could be pregnant? If so we can not carry out this treatment due to products used and for insurance purposes(Required) Yes No Please provide any further details that may help your therapist Please note our cancellation policy is 48 hours - less than 48 hours full cost of the appointment will be charged(Required) I agree to the privacy policy. And give Cryo Solihull to store my details under GPDR compliance.Date MM slash DD slash YYYY Δ
