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MADA Clinic and spa

The Best Laser and Skin Clinic in Dublin

Advanced treatments

Natural results
Men and Women

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Facial Form

Please take a moment to fill out the form.

First Name

Last Name

Email

Birthday

Email

Phone

Have you used Roaccutane or Accutane, topical medications or antibiotics in the past 6 months?

Are you currently pregnant or lactating?

Do you have a skin cancer history, malignant mole or precancerous lesions?

Have you had recently any aesthetic procedure on the area of the treatment (mesotherapy, peeling, resurfacing, fillers)? If yes, how long since the last procedure?

Do you have active skin diseases and conditions on the area of treatment?

Eczema

Psoriasis

Dermatitis

Acne

Burnt / Injured skin

Sensitive skin

Rosacea

Herpes Simplex

Rash

None of the above

Do you have any of the following in the treatment area?

Vascular disorders

Uncontrolled diabetes

Nervous system disease

Cardiac disorders

Epilepsy

Pacemakers

Defibrillator

Nerve stimulator

In-vivo electrical device

Metal implant

None of the above

I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinol that are not part of the recommended take-home regime in the treated areas for minimum 2 weeks pre-and post-treatment.

The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the Hydracool Plus treatment by the staff at Clinic.

By signing below, I acknowledge that I have read the above information and give my consent to be treated with the Hydracool Plus

This consent form is valid for all future Hydracool Plus treatments. I will alert the staff if there are any future changes to my medical history.

I hereby authorize MADA Clinic and Spa to use my photo and/or information related to my experiences with my treatment with associated devices and products. I understand this information may be used in publications, presentations, promotional literature, advertising, social media and/or other similar ways.

Date of signing

Your Signature

Thanks for submitting!

I hereby authorize MADA Clinic and Spa to use my photo and/or information related to my experiences with my treatment with associated devices and products. I understand this information may be used in publications, presentations, promotional literature, advertising, social media and/or other similar ways.

I hereby authorize MADA Clinic and Spa to use my photo and/or information related to my experiences with my treatment with associated devices and products. I understand this information may be used in publications, presentations, promotional literature, advertising, social media and/or other similar ways.

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Opening hours

(Monday, Sunday by appointment)

Monday : 11am-7pm

Sunday: 11 am- 7pm

Tuesday- Friday: 11 pm - 8pm
Saturday: 10 am-6 pm

Address: Unit 2, Block E, Thundercut Alley, Queen St, Smithfield, Dublin 7, Ireland

Customer Service

Email: info@madaclinicspa.com

Phone: 01 575 9865

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