Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

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Have you recently tanned your skin? *

Yes - Sun Tan/ Tanning Bed

Yes - Fake Tan

No

Medical Conditions *

Please tick all that apply (if none apply please select "None of the above"

Allergies to anaesthetic based topical agents

History of abnormal response to sunlight

Photo sensitizing medications or drugs

Have used isotretinoin (Accutane) within the last 6 months

Currently Pregnant or possibility of being Pregnant

Any medical conditions that may affect wound healing

Taking anticoagulant medications or heavy aspirin use

Active infections and/or a compromised immune system

History of skin cancer, especially malignant melanoma

History of keloid scar formation

Epilepsy

None of the above

Acceptance of Competition Terms and Conditions *

Please confirm that you have read and accept our competition terms and conditions:

Yes, I have read and accept the competition terms and conditions

Date

MM

DD

YYYY