BOTOX
Consultation Form
Name
*
First Name
Second Name
Date of birth
*
-
Dzień
-
Miesiąc
Rok
E-mail
*
Phone Number
*
-
+44
Phone number
Address
*
Do you confirm that your personal details on this medical form are correct?
*
YES
NO
Add comment here
Do you have any known health conditions or medical history?
*
YES
NO
Add comment here
Are you currently under investigation or waiting for a specific diagnosis?
*
YES
NO
Add comment here
Do you take any regular medications?
*
YES
NO
Add comment here
Do you have any allergies?
*
YES
NO
Add comment here
Have you had any aesthetics/cosmetic treatments in the past?
*
YES
NO
Add comment here
Have you had any issues with any aesthetics/cosmetic treatments in the past?
*
YES
NO
Add comment here
Do you understand what aesthetics procedure you are having? If so, what has been discussed?
*
YES
NO
Add comment here
I confirm the above medical information is accurate to the best of my knowledge and accept responsibility for any errors.
*
Yes, I confirm
Signature
*
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