Vitality Aesthetics Consent & Medical Questionnaire

Full Name*

First NameLast Name
Date of Birth*

YearMonthDay
Date
Phone Number*

Area CodePhone Number
E-mail*
What Services Are You Interested In?

Fuller LipsWrinkle ReductionDermal Fillers such as fuller lips, cheek augmentationLaser Hair RemovalCellulite Reduction / Skin TighteningPRP TherapyMicroderm Abrasion or Needling
Are you pregnant or breastfeeding?*
Do you have any history of severe allergy/anaphylaxis?*
Are you currently receiving any medical treatment?*
Have you previously had any aesthetic treatments?*
If yes to any of the previous questions, please give details in the box below:
Fillers such as Juvederm or Voluma, Botox, PRP Therapy
Have you ever tested positive for HIV or Hepatitis?*
Do you suffer from keloid or hypertrophic scarring?*
Do you have a phobia of needles or suffer from fainting attacks?*
Have you had any dermal filler treatment?*
If yes, which treatment did you receive, what areas and when?
Do you have any skin infections or inflammatory problems (e.g. herpes, acne etc)?*
Do you suffer from myasthenia gravis or Eaton Lambert syndrome?*
Do you suffer from any allergies?*
If yes, please give details:
If you answered yes to any of the questions within the medical questionnaire, your practitioner may ask for further details. Treatment may be refused if it is not considered in your own interest to proceed.

Click submit to complete your form. Thank you, VitalityDermCare

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