Aesthetics Consultation Form

First Name: *

Surname: *

D.O.B *

Address: *

Telephone: *

Email: *

Doctor's Name: *

Doctor's Address:

Doctor's Phone:

Medical History

Are you currently receiving any medical treatment? *

Please give details:

Have you had any dermal filler treatment or botulinum toxin? *

Which treatment did you receive, what areas were treated and when?

Have you had any another aesthetic treatment such as Dermal Roller, Dermaplaning or Semi-permanent makeup? *

Which treatment did you receive, what areas were treated and when?

Are you currently taking any medication or supplements? *

Please give details:

Have you had any previous surgery? *

Please give details:

Do you have any allergies/intolerances? *

Please give details:

Have you had cold sore breakouts (oral herpes) in the past year? *

Please give details:

Do you have ANY current or chronic medical illness, specifically: Myasthenia Gravis, Amyotropic Lateral Sclerosis, or any other Neuromuscular disorders? *

Please give details:

Do you have history of Keloid Scarring? *

Please give details:

Have you suffered from any of the following?

ANY ADDITIONAL NOTES/COMMENTS:

For Women

Are you or could you be pregnant? *

Yes No

Are you breast feeding? *

Yes No

If you have any questions about the above please discuss these with your practitioner. If the answer is yes to any of the above, your practitioner may ask for further details. Treatment may be refused if it is not considered in your own interest to proceed.

I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks. I confirm that all information provided above is true and accurate.

It is your responsibility and not that of the therapist to consult your GP or consultant. By signing this form you are hereby indemnifying the therapist against any adverse reaction sustained as a result of the treatment.

Signed:

Signed: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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