Philips IPL LUMEA Pre Sales form

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

*Required

Beauty Advisor Details

Who filled this form? *

Store Staff
Epik Promoter
Other

Name *

Date *

Store Name *

Select trial location *

At - Croma Store
At - Tira Store
At - Home
Other

Product Trial Feedback

Does the customer have a matching skin and hair color according to the given chart?

What is the skin tone of the customer? *

What is the customer's hair colour? *

Did the Device get unlocked on the customer? *

Area of concern?

Face (Upper Lip,Chin, Jawline)
Underarms
Bikini Line
Legs
Other body parts

Has the customer previously used an IPL device? *

Is the customer currently pregnant or breastfeeding? *

Does the customer have any skin conditions, such as eczema, psoriasis, or active sunburn? *

Is the customer aware of and comfortable with the treatment schedule (every 2 weeks initially)? *

Does the customer understand that treatment results may vary according to their skin tone and hair color? *

Customer Personal Information

I confirm that the customer has agreed to the collection, storage, and use of their personal information for this purpose, in accordance with our privacy policy. *

Customer Name *

Customer Email Id *

Customer Contact Number *

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

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