DERMAL FILLER (also includes dissolving with Hyaluronidase)
CONSULTATION FORM
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Are you currently taking any medical or dental treatment?
*
Yes
No
Please give details
In the last one month, have you had any dermal treatments such as tattoos, dermal fillers, piercings or botulinum toxin?
*
Yes
No
Please give details
Do you have any allergies in your knowledge?
*
Yes
No
Please give details
Do you have any relevant past medical history
*
Yes
No
Please give details
Have you recently received your COVID-19 vaccination?
Yes
No
Please select if you you suffer from any of the conditions listed below
*
Blood Bourne Virus
Epilepsy
Respiratory Conditions
Myasthenia gravis or Eaton Lamberts Syndrome
Immunodeficiency
Herpes Simplex Virus (Coldsores)
Hypertrophic Scarring
Rheumatic Fever
Acne or Inflammatory Skin Conditions
Blood Disorders
Anaphylaxis/severe allergy
Porphyria
Cardiac Conditions
Recurrent Sore Throats
None of the above
Other
Please give details
Are you having previous filler dissolved with Abigael Eva Aesthetics?
*
Yes
No
Not having dissolving
If yes the previous filler done with Abigael Eva Aesthetics?
*
Yes
No
Not having dissolving
If dissolving please specify the area for dissolve and any information you may know from your treatment (ie amount and/or brand of filler, how long ago the filler was done and has any dissolve been done before)
If dissolving is this dissolve elective or emergency?
*
Elective (I am choosing to have this dissolve for aesthetic reasons)
Emergency (a VO complication has occurred and the filler needs dissolving for medical reasons)
Not having dissolving
Do you have any known allergies to Hyaluronidase?
*
Yes
No
N/A
For dissolving a patch test injection will be carried out on the forearm prior to dissolve treatment to check for any sign of allergy, I understand this is required for my safety and if an allergy is present I will not be able to have the treatment done.
*
Yes
No
N/A
Do you want to add something?
*
I confirm that all information indicated in this form is true and accurate.
*
I agree to the deposit and cancellation terms on Abigael Eva Aesthetics & Beauty’s booking system. Deposits are non-refundable. I understand that less than 72 hrs notice will incur a cancellation fee of the deposit amount. If more than 72 hours notice is given my deposit can be transferred to another date, I have the option to do this once for my booking. Abigael Eva Aesthetics reserves the right to cancel/change the booking due to illness, injury or extenuating circumstances and best efforts will be made to find the next available appointment for my treatment; my deposit will be transferred to my chosen date in this event.
Sign
*
Date
*
-
Day
-
Month
Year
Date
SCROLL TO BOTTOM TO SUBMIT
(Below doesn't need filling until treatment date)
For treatment date:
Client Record
Rows
DD/MM/YY
Area of filler
Filler ml
Brand of filler
Aftercare received
Notes
Date:
Lips
Cheeks
Tear troughs
Jawline
Rhinoplasty
Naso folds
Marionette lines
Smokers lines
Chin/jowl
Filler facelift
Multiple areas
0.5ml
1ml
2ml
3ml
4ml
Lumifil
Mona Lisa
Glowing fill
Teoxane
Genius
Please rate your treatment
1
2
3
4
5
Signature
Rows
DD/MM/YY
Area of filler
Filler ml
Brand of filler
Aftercare received
Notes
Date:
Lips
Cheeks
Tear troughs
Jawline
Rhinoplasty
Naso folds
Marionette lines
Smokers lines
Chin/jowl
Filler facelift
Multiple areas
0.5ml
1ml
2ml
3ml
4ml
Lumifil
Mona Lisa
Glowing fill
Teoxane
Genius
Please rate your treatment
1
2
3
4
5
Signature
Rows
DD/MM/YY
Area of filler
Filler ml
Brand of filler
Aftercare received
Notes
Date:
Lips
Cheeks
Tear troughs
Jawline
Rhinoplasty
Naso folds
Marionette lines
Smokers lines
Chin/jowl
Filler facelift
Multiple areas
0.5ml
1ml
2ml
3ml
4ml
Lumifil
Mona Lisa
Glowing fill
Teoxane
Genius
Please rate your treatment
1
2
3
4
5
Signature
Submit
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