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 breakoutsLaser for Freckle, dark spotsMoles, Skin Tags, Skin BumpsMelasmaSensitive skinSkin rashBlemish & Scar removalBirthmarkSkin Lightening & Color CorrectionFacial Revival & NourishmentLaser Skin ResurfacingLine & wrinkle correctionSkin texture correctionSkin RejuvenationSkin Pore TighteningDarken LipEyes issue: Dark eye circle, wrinkles. hollownessUnderarm issue: brightening, smoothingHair RemovalHyperhidrosis(excessive sweating)Excessive sweating/body odorVaricose vein/spider veinTattoo removalFacial Design & Age-Defying TreatmentAnti-Wrinkle injectionsBrow & Eyelid liftingFiller ProgramFace LiftingFacial Line Correction & Age Defying TreatmentV-shape faceSkin tighteningSubmental & Neck Lifting /TighteningAnti-Cellulite treatmentBody contouring & Weight LossStretch MarkCalf reduction & ReshapingHair thinning, Baldness & Hair LossDandruffHair Regrowth TherapyCO2 laserFraxel:Dual Laser ProgramFractite Pro Face&Neck LiftingFractora ProgramForma ProgramForma Plus ProgramMorpheus8 Program (Microneedling RF)Healite II ProgramPicoWay Laser ProgramPicoWay Zoom 1064 532 ProgramPicoWay Fusion 532 ProgramPicoWay Resolve 1064 532 ProgramPicoWay 730 ProgramRevlite Laser ProgramLutronic Spectra Gold ProgramQ-switch pigmented laserIPL Pigmented & PhotorejuvenationB&C Vascular laserUlthera Program: Non-invasive face liftUltraformer III ProgramUltrashape Power ProgramSkin tight plus programBody FX ProgramLiposonix ProgramLaser Hair Removal (Cutera Program)Laser Tattoo Removal (PicoWay 1064 532 Program)Sclerotherapy(Correction of veins, spider)Scar SubcisionVascular laser (Cutera Program)Mesotherapy ProgramOther please specify

Treatment that you look for:*

Any previous treatment:*

Consent for Medical Imaging and Data Use*
I hereby grant my explicit consent to BSL Clinic, including its affiliates, personnel, and any authorized agents acting on its behalf, to collect, retain, and process my photographs and digital images (hereafter referred to as “Material”) exclusively for medical purposes. These purposes include medical documentation, clinical evaluation, diagnostic comparison, and internal record-keeping as part of my confidential medical file.
The Material will not be used for advertising, public dissemination, or any non-medical purposes without prior written authorization from me. All data will be securely stored in compliance with the PDPA and treated with the strictest confidentiality. I retain the right to access, review, or request deletion of the Material in accordance with applicable data protection laws. Consent may be revoked in writing at any time and will affect future processing only.
If you have any questions or would like to exercise your rights under PDPA, please contact our Data Protection Officer (DPO) at: [email protected]

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

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

Send me a copy of my responses