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

      Contents

• Your Contact Information

• Personal Information

• Treatments

• Other Treatments

• Brief Description

• Required Date

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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	Blonde Brown Black Red Gray White
Eye Color	Blue Brown Black Green Gray Violet

          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 :