SKIN BOOSTERS
Consultation Form
Name
*
First Name
Second Name
Date of birth
*
-
Dzień
-
Miesiąc
Rok
E-mail
*
Phone Number
*
-
+44
Phone number
Address
*
Are you attending or receiving treatment from a doctor or specialist? If yes, please specify
*
YES
NO
Add comment here
Are you taking any medication, or herbal remedies (including antibiotics, anticoagulants, muscle relaxants, St Johns Wart, Roaccutane)?
*
YES
NO
Add comment here
Have you undergone any major surgery in the last 12 months?
*
YES
NO
Add comment here
Are you currently undergoing dental surgery?
*
YES
NO
Add comment here
Are you taking blood thinning medication (Aspirin, Plavix, Warfarin)?
*
YES
NO
Add comment here
Are you allergic to local anaesthetic injections, lignocaine, adrenaline or EMLA/ANESTOP cream?
*
YES
NO
Add comment here
Do you have any known allergies or a history of anaphylaxis?
*
YES
NO
Add comment here
Have you suffered from or had any of the following conditions?
*
YES
NO
Add comment here
Heart Problems including an irregular heartbeat or angina?
*
YES
NO
Add comment here
High or Low Blood Pressure or circulation problems including Raynaud’s SyndromeEpilepsy/Blackouts/fainting?
*
YES
NO
Add comment here
Autoimmune disease?
*
YES
NO
Add comment here
Diabetes?
*
YES
NO
Add comment here
Contact Dermatitis/Eczema?
*
YES
NO
Add comment here
Keloids (hypertrophic scarring) or recent scar tissue (6 months)?
*
YES
NO
Add comment here
Easy Bruising?
*
YES
NO
Add comment here
Facial Herpes, Cold Sores or acne?
*
YES
NO
Add comment here
Skin Cancer?
*
YES
NO
Add comment here
Psychiatric illness/depression?
*
YES
NO
Add comment here
Do you smoke?
*
YES
NO
Add comment here
Do you use sunbeds or sunbathe?
*
YES
NO
Add comment here
Have you had an allergic reaction to any product?
*
YES
NO
Add comment here
Any other medical conditions that you feel may be relevant, please specify:
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
*
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Day
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Month
Year
Date
Signature
*
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