Fresh Faced Aesthetics & Skincare clinic
Medical consultation Form
Date of face to face consultation
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender
Please Select
Male
Female
Email
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you consent to your information being shared in the event of an emergency
Medical Data
Do you suffer from any allergies
Yes
No
Are you currently pregnant or trying to conceive
Yes
No
Do you have any known allergies? If yes, then please specify below.
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma etc.?
Do you suffer from any blood disorders
Yes
No
Currently on any blood thinners
Yes
No
Acknowledgment, Authorization and Waiver
Have you had any injectables before
Botox
Dermal fillers
Lip fillers
Microneedling
Patient/Client Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Are you currently pregnant or breastfeeding
Yes
No
Submit
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