Atlantic Beauty-online assessment

Suitability assessment for patients interested in aesthetic treatments (Botox, Fillers).

The purpose of this to give preliminary advice and prepare the practitioner for a face-to-face consultation. All your data will be kept strictly confidential in accordance with GDPR.
Name*

First NameLast Name
Email*
example@example.com
Phone Number

Area CodePhone Number
How should we contact you?

EmailPhoneBoth
Medical History
If you have you any of these symptoms

High Fever

New continuous cough

Loss or change of smell and taste

Please visit https://111.nhs.uk/covid-19
Are you taking any medicine or tablets prescribed by your doctor?*

YesNo
Please list your current medication. If you are NOT taking any medication, please fill in "NONE". *
Are you receiving any medical treatment at present?*

YesNo
Please submit details about your medical treatments. If you are receiving any treatment, please fill in "NONE". *
Do you suffer form headache or migraine? If yes, when and how often?
Your specific concerns

Face
Please describe your concerns.
Important: Please, upload a front and profile photo of your face.

Browse Files

Cancelof
Other services for you
I am interested in further information about:

Cosmetic DentistryDental ImplantsCryolipolysis ("FatFreezing")None
Additional Comments
I agree to Atlantic Beauty using my personal data to provide me with advice and dental treatment.*

Yes
Please verify that you are human*
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Suitability assessment for patients interested in aesthetic treatments (Botox, Fillers).