Consultation Booking Pre-Screening Form

Consultation Booking Pre-Screening Form
Name

First NameLast Name
Birth Date

DayMonthYear
Email
example@example.com
Telephone
Telephone
Please check YES or NO next to each question.
a. Are you currently pregnant breastfeeding or planning a pregnancy in the next 3 months?
b. Have you any known allergic reaction to Botulinum toxin type A or any inactive ingredients ( e.g. Human Albumin)
c. Do you have any skin infections or open wounds around the treatment sites (e.g cold sores/herpes simplex)
d. Do you suffer from any Neuromuscular disorders, such as Myasthenia Gravis, Lambert-Eaton myasthenic syndrome or amyotrophic lateral sclerosis?
e. Within the last 14 days have you taken aminoglycoside antibiotics? (e.g gentamicin)
Signature
Date Signed

DayMonthYear
Date
Should be Empty: