Emergency Contact Name Contact Name Emergency Contact Mobile No Mobile Number
Do you have children? No Yes2 If yes, how old are they?how many children.
Do you smoke cigarettes?No Yes2 If yes, how many per day?how many children.
Do you use sunbeds? No Yes2 If yes, how often?how many children.
Do you wear sunscreen daily? No Yes2 If so, what SPF Factor do you use?how many children.
Does you sunscreen have a PPD Index?No Yes2 If yes, what is the PPD index?how many children.
Do you use a topical antioxidant?No Yes2 If yes, what is the topical antioxidant?how many children.
Do you have any marks or blemishes on your skin that have changed or seem not to be able to heal?No Yes2 If yes, please provide details?how many children.
Answer the following questions with a YES or a NO and give further details where required.
Have you ever had cancer? No Yes If so, What type and how long ago?how many children How long ago .
Do you have ,or have you previously had, any other medical condition not alreadymentioned here? If yes, please give details: medications / supplements
Are you currently receiving any medical treatment? No Yes If yes, please give details: medications / supplements
Have you received any chemotherapy or radiotherapy in the last 12 months?No Yes If yes, please provide details: Type of filler .
Have you had any surgery or physical injury in the last 12 months ? No Yes If yes, please give details: medications / supplements