Full Name
*
First Name
Last Name
E-mail Address
*
example@example.com
Phone (Mobile)
*
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Format: (00000) 000000.
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Date of Birth
*
Please select a day
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Day
Please select a month
January
February
March
April
May
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September
October
November
December
Month
Please select a year
2026
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Year
Emergency Contact (Please provide name, relationship to client and contact information)
Where did you hear about us?
*
Google / website
Social Media
Business card / flyer
Friend / Client recommendation
Name of your GP
GP Surgery / Address
*
GP Surgery Phone Number
*
Have you ever had any of the following? Please tick all that apply:
Facial cold sores (herpes simplex)
Skin disorders (eczema, rosacea / acne / vitiligo / keloid scaring)
Are you pregnant or breastfeeding
Diabetes
Thyroid problems
Tumours / abnormal swelling
High/Low blood pressure
Heart disease / Angina
Bleeding disorder
Excessive bleeding
Psychological disorders (depression / anxiety / eating disorder / personality disorder)
Liver disease
Kidney Disease
Auto-immune disease
Headaches
Bell's Palsy / Facial palsy
Hearing or speech problems
Epilepsy / seizures
HIV/Hepatitis
Other medical condition not listed above
Please provide further detail about your past medical history:
Do you suffer from allergic reactions anaphylaxis
*
No known allergies
Latex allergy
Bee sting / wasp sting allergy
Do you carry an epipen? (emergency adrenaline injection for allergies)
Other
If you answered that you suffer from an allergy of some descriptions - please provide further detail below:
Do you smoke?
*
Please Select
Yes - Current smoker (>10 per day)
Yes - Current Smoker (1-10 per day)
Ex - smoker
No - never smoked
Are you taking any prescribed medications, over the counter medicines, drops or topical lotions or any dietary / herbal supplements?
Yes
No
Please list all medications / supplements / drops / lotions you are taking:
Do you drink alcohol?
*
Please Select
Yes
No
If Yes, how many units of alcohol to you consume on a weekly average?
Have you had any of the following in the last 12 months (Tick all that apply)
General anaesthetic
Local anaesthetic
Cosmetic surgery
Antibiotics
Severe allergic reaction
Medication for skin (i.e. Roacataine)
Liposuction
Surgical facelift
Please provide further details.
Have you received any of the below in the last 6 months?
Anti-wrinkle injections ("botox")
Dermal filler
Laser Hair removal
Laser treatments
Microdermabrasion
Chemical peel
Waxing in the area to be treated
Microneedling
Microblading / Tattooing
Threads
Fat dissolving injections / body sculpting treatments
Please provide further details of your treatments within the last 6 months:
What specific concerns to you have that you would like the ReNu team to help you with?
Are there specific treatments / services that you would like us to tell you more about when you visit?
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?
Yes
No
I have completed this medical history form and confirm that this information is true and correct to the nest of my knowledge at the present date. I have been informed that I have to review, update and sign a new medical history form at all further examination or consultation appointments in line with practice policy.
*
I Confirm
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
*
I Confirm
Date
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Date
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