Photo Submission Form – BSL Clinic

Please complete this form and attach clear photos of the area(s) you are concerned about or would like to consult with us regarding before your visit.
The information and photos you submit will be used for an initial assessment and to help our medical team plan the most suitable care for you.

If you would like to submit more than one set of photos, please complete this form and upload the first full set of images from all relevant angles (for example: front view, side view, etc.) first.
After that, you may return to this form and submit the next set of photos separately.

Once the clinic has received and reviewed your information, our team will contact you to inform you of the next steps.
If you have any further questions, please feel free to contact us at [email protected]

Your Full Name *

Your Contact Email Address *

Your Contact Phone Number *

What concern or issue would you like to consult about? *

Which treatment or service are you interested in? *

Please specify any previous treatments or services you have received, such as facial treatments, laser treatments, etc. *

Consent for Use of Photographs *

I hereby consent and authorize BSL Clinic, including its affiliated companies, representatives, or any persons assigned by the clinic (collectively referred to as “BSL Clinic”), to use my photographs and digital images (“Images”) taken for treatment evaluation, medical education, professional training, publication in professional articles, or for advertising and promotional purposes. The clinic will not use any images that can identify me personally unless my written consent has been obtained in advance. However, if the images do not reveal my identity, such images may be used, displayed, or publicly published without further permission.

I consent to BSL Clinic using such images in advertising media such as posters, videos, websites, product packaging, brochures, or other media, and I allow the clinic to edit, publish, or distribute them as deemed appropriate. I hereby assign all rights in such images to BSL Clinic and waive any right to inspect or approve any advertising materials containing my images.

I have read and understood all the details in this form and agree to the stated terms and conditions. By checking the box below, I confirm my consent to this agreement.

I agree to the terms and conditions stated above

Upload Files *

Please attach photos of the area you would like to have evaluated.
Please upload:
1. Before-treatment photos – in the highest resolution possible.

(10 mb)
(10 mb)
(5 mb)

Enquiry Form – EN

Photo Submission Form – BSL Clinic

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