Medical History Form (Injectables)

Welcome to ReNu Medical Aesthetics

Thank you for taking the time to complete this form before your appointment. It will help me better understand your health, skin concerns, lifestyle and treatment goals ahead of your consultation. All information is confidential and stored securely. If there is anything you would prefer to discuss in person, please feel free to leave sections blank and we can discuss them during your consultation. I look forward to meeting you soon. Dr Jackie Martin

SECTION 1: About you

Section 1 of 9
Full Name

First NameLast Name
Date of Birth

DayMonthYear
Phone (Mobile)
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E-mail Address
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Emergency Contact (Please provide name, relationship to client and contact information)
GP Surgery / Address
GP Surgery Phone Number
Where did you hear about us?

SECTION 3: Medications & Allergies

Section 3 of 9
Are you taking any prescribed medications, over the counter medicines, drops or topical lotions or any dietary / herbal supplements?
Please list all medications / supplements / drops / lotions you are taking:
Do you suffer from allergic reactions anaphylaxis

Other
Please provide details including the type of reaction experienced:

SECTION 8: Communication & Photography

Section 8 of 9
Clinical photography forms an important part of your medical record and may be used to assess treatment progress. Do you understand and consent to clinical photographs being taken and securely stored?
Would you be happy to receive information regarding future treatments, skincare or clinic updates from ReNu?

SECTION 9: DECLARATION

Section 9 of 9
Do you have any important upcoming events, holidays or commitments we should consider when planning treatment? Please provide details.
I confirm that the information provided is accurate and complete to the best of my knowledge at the present time. I understand that it is my responsibility to inform the ReNu doctor of any changes to my medical history, medications or circumstances prior to treatment.
I understand that I will be required to sign a consent form and allow photographs to be taken as a record pre / post my treatments
Signature
Date

DayMonthYear
Date
Should be Empty:

Welcome to ReNu Medical Aesthetics