- Laser
- Skin

 

Please provide us with the following information.

Your details at no time will be disclosed to any third party. Information provided here will be confidential and use only for the purpose of treatment.

 

You can info@bankriscanada.com

 

Address:

1718-A Lakeshore Rd. West

Mississauga -Ont. L5J1J5

Tel: 905.823.8111

 

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        Please provide the following contact information:

First Name

Last Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

Home Phone

FAX

E-mail

          Please identify and describe yourself:

Age

Sex

Male Female

Height

Weight

Hair Color

Eye Color

          Treatment Related Information ( Select any of the following options that apply)

Permanent Hair Removal for Face & Body             
Microdermabrasion Scars & Pits                     
Removal of Couporse, Spider Veins, Skin Tags,      
Removal of Pigmentation, Acne,        
Removal of Cholesterol Deposits & Vascular Blemishes
IPL Non-Surgical Therapy for Wrinkles, Lines & Aged Skin
Removal of Skin Tags & Freckles                  
Permanent Make up of Eyes Lips & Beauty Spot       
Glycolic & Oxygen Facials for Problematic Skin & Body
Aroma Facial & Body Massage                      
Spa

            Enter any other Treatments in the space provided below.

           Provide brief description of your treatment requirement

           Required Date :

 

 

GET RID OF:

    * Wrinkles lines and folds

    * Age spots & sun Damage

    * Coarse skin and large pores 

    * Whiteheads / Blackheads

    * Dilated capillaries

    * Rosacea

 

 

 
 
 
 
 
 
 
 
 
 
 

Copyright ©2004 Bankris Laser & Skin Care Clinic. All rights reserved.