Scar Revision Consultation Form

Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Age*
Occupation*
Where is the scar that you would like repaired?*
Please include clearly taken photos of the scar that you would like repaired.*

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Do you smoke? If yes, how many per day?*
How often do you consume alcohol?*
Do you have any allergies?*
Do you suffer from any of the following?*

AsthmaDiabetesEpilepsyCold SoresBacterial InfectionBlood ClotsThyroid DiseaseHeart ProblemsImmune DisordersBad ScarringCancerViral InfectionsHIV/AIDsHigh or Low Blood PressureBleeding DisordersHepatitis B or CPsychiatric TreatmentNone of the above
Please list any past or present medical problems or conditions*
Have you have any surgeries or operations in the past?*

YesNo
Were there any complications with infection or anaesthetic?*
Are you currently taking any prescription or non-prescription medications? Including supplements and herbal? If yes, please specify.*
Are you currently pregnant or breastfeeding?*

YesNo
Do you exercise regularly? If yes, what type of exercise?*
Are you still wearing jewellery in your piercing?*

YesNo
When was your jewellery removed?
How much water do you consumer per day?*

250mL500mL750mL1L1.5L2L2L+
Do you consume caffeine on a regular basis? If yes, how much/how often?*
When was the last time that you had a blood test to check health?*
Were there any issues with iron, Vitamin D and/or B12? If no, have you ever had issues with these vitamins?*
Please list any further key information regarding your chosen procedure and if you would like for us to contact you to schedule an appointment, or if you would just like to know if you are a suitable candidate for the treatment.*
Once you have submitted this form with all of the information required, we will assess the information required to determine your suitability for your chosen procedure. We will then contact you via email with the next steps on booking your procedure.
I have read the "Prepare For Your Procedure", "FAQs", "Aftercare" and "Pricing" pages at scar-revision.cherrycore.com.au*

Yes, I have read this informationNo, I have not read this information
Please do not check the above unless you have read all information listed.

All information is provided for you; it is your responsibility to be procedure ready and informed.
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