Consultation Consent Form
Dr Izabella Bennett Aesthetics Clinics
Customer Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Medical Information: Please answer the following questions accurately. This information will help your aesthetic doctor provide you with the safest and most appropriate treatment.
Do you have any pre-existing medical conditions?
Do you take any medication?
Do you suffer from eczema, psoriasis, dermatitis or other skin conditions?
Do you have any broken skin on the area being treated?
Do you have any allergies?
Do you suffer from frequent eye irritation, itching or watery eyes?
Do you suffer from frequent eye irritation, itching or watery eyes?
Are you pregnant or breastfeeding?
Do you suffer from epilepsy or any seizures?
Have you had any recent trauma, surgery?
Do you have a history of cold sores (Herpes Simplex)?
If you answered YES to any of the above, please elaborate here, including frequency and any treatments used:
Do you give permission for your photographs (with no name or identifying details) to be used for educational or promotional purposes (e.g. website, social-media)?
YES
NO
Submit
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