PRP, PRF
Consultation Form
Name
*
First Name
Second Name
Date of birth
*
-
Dzień
-
Miesiąc
Rok
E-mail
*
Phone Number
*
-
+44
Phone number
Address
*
Do you have any medical conditions?
*
YES
NO
Add comment here
Are you pregnant or breastfeeding?
*
YES
NO
Add comment here
Do you have a neuromuscular disease (e.g. MS, ALS, motor neuropathy myasthenia gravis, orLambert-Eaton syndrome)?
*
YES
NO
Add comment here
Do you have an autoimmune disease?
*
YES
NO
Add comment here
Do you have any skin conditions?
*
YES
NO
Add comment here
Do you have any known allergies or have ever had anaphylaxis?
*
YES
NO
Add comment here
Do you have any active infection at the intended site of procedure?
*
YES
NO
Add comment here
Are you taking antibiotics or other prescription medications?
*
YES
NO
Add comment here
Is there any other Medical and/or Social History that we should know? If so, please provide full detail here.
*
YES
NO
Add comment here
Have you had this or a similar treatment before? If so, did you experience any problems? Pleaseprovide full details here.
*
YES
NO
Add comment here
Do you have any concerns? If so, please provide full details here.
Is there anything else we should know? Please provide full details here.
Confirmation
I confirm the health history is accurate and complete. I understand that withholding any medical information may be detrimental to my health and safety during the procedure which the practitioner agrees to undertake. If there are any changes in my medical history, it is my responsibility to advise the practitioner before any further treatments are carried out. I agree that I understand the treatment I am having today, and the possible risks associated with these procedures.
Date
*
-
Day
-
Month
Year
Date
Signature
*
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