Treatment Form

1

Full Name* This field is required.

First Name

Last Name

2

Address* This field is required.

Street Address

Street Address Line 2

Town/ City

County

Postcode

Country

3

Contact Number* This field is required.

4

Date of Birth* This field is required.

5

E-mail* This field is required.

6

Preferred method of contact* This field is required.

7

Are you over 18 years of age?* This field is required.

YESNO

8

Are you pregnant or breastfeeding?* This field is required.

YESNO

9

Are you / will you be under the influence of alcohol or illegal drugs at the time of your procedure?* This field is required.

YESNO

10

Do you feel fit and well and able to have a cosmetic procedure done?* This field is required.

YESNO

11

I agree to photographs being taken BEFORE, DURING and AFTER my procedure which will be kept in my case file, or used only with my written consent for promotional purposes.* This field is required.

YESNO

12

Do you have any allergies or have you experienced an allergic reaction to medicine or products (such as latex, plaster, nickel etc)?* This field is required.

YESNO

13

Do you have or are you having injectables, fillers or chemical peels?* This field is required.

YESNO

14

Do you have any imminent holiday plans?* This field is required.

YESNO

15

Do you have any keloid scarring?* This field is required.

YESNO

16

Do you suffer from epilepsy and have had a seizure in the last 2 years?* This field is required.

YESNO

17

Do you suffer from Haemophilia?* This field is required.

YESNO

18

Do you knowingly have any infectious diseases?* This field is required.

YESNO

19

Do you knowingly have Hepatitis C?* This field is required.

YESNO

20

Do you suffer from shingles?* This field is required.

YESNO

21

Do you suffer from cold sores, fever blisters or skin disorders in the area to be treated?* This field is required.

YESNO

22

Do you have diabetes?* This field is required.

YESNO

23

Do you have any respiratory problems?* This field is required.

YESNO

24

Do you suffer from or have any problems with wound healing?* This field is required.

YESNO

25

Do you take blood thinners or anti- inflammatories?* This field is required.

YESNO

26

Do you take Antabuse?* This field is required.

YESNO

27

Do you take Roaccutane?* This field is required.

YESNO

28

Do you have high or low blood pressure?* This field is required.

YESNO

29

Do you wear contact lenses or suffer from glaucoma?* This field is required.

YESNO

30

Are you currently taking any medication?* This field is required.

YESNO

31

Are you 5 weeks pre or post radiotherapy/ chemotherapy treatment?* This field is required.

YESNO

32

Are you allergic to any local anaesthetics? * This field is required.

YESNO

33

You understand that for 24 hours post treatment you should avoid using any active skincare that contains AHA, Retinols/Vitamin C or oil-based makeup

YESNO

34

You understand that after your treatment you may experience some small, raised bumps around the treated area, some slight redness or red needle puncture marks. These should subside within a few hours.

YESNO

35

You understand that for 24 hours post treatment you should avoid strenuous exercise and alcohol

YESNO

36

You understand that for 2 weeks after your treatment you should avoid facials, facial waxing, chemical peels, IPL or energy-based treatments

YESNO

37

You understand that you should not expose your skin to intense heat for 24 hours post treatment

YESNO

38

You understand that there might be some bruising to the treated area post treatment

YESNO

39

I understand the importance of providing accurate and complete medical history and that withholding any medical conditions may be detrimental to my health and the outcome of the procedure.* This field is required.

YESNO

40

I understand there are no guarantees as to the success and longevity of my treatment. * This field is required.

YESNO

41

I accept these terms and hereby give my written consent for my trained specialist to carry out the course of treatment of my choice.* This field is required.

YESNO

42

Signature* This field is required.I certify that i have read and i have had explained to me, and fully understand to above consent form and that i have requested to have permanent cosmetic enhancement of my own free will.

Clear

43

Date* This field is required.

Date