Consultation Booking Pre-Screening Form

Consultation Booking Pre-Screening Form
Name

First NameLast Name
Birth Date (Please confirm you are over 18 years old)

DayMonthYear
Email
example@example.com
Telephone
Telephone
Please check YES or NO next to each question.
a. Are you currently pregnant, nursing or planning a pregnancy in the next 3 months?
b. Have you any known history of severe allergies/ hypersensitivity to complex proteins or previous adverse reactions to injectable aesthetic treatments?
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 chronic neuromuscular disorders or muscle weakening conditions? (e.g 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
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty: