REGISTRATION FORM & MEDICAL QUESTIONNAIRE
Name
Mr.
Mrs.
Ms.
Miss
Dr
Title
First Name
Last Name
Email
Best Contact Number
Alternative Number?
Date of Birth
Occupation
Address
Next of Kin
Phone
Ethnicity
Please tell us about
Any medical conditions
All regular medication / supplements
Any allergies to medication or foods
Have you ever had:
Rows
Yes
No
An anaphylactic reaction
Problems with anaesthetics
Muscle disorder or problems
Hepatitis / TB / HIV
Recurrent cold sores
Acne / rashes / eczema / rosacea
Any other skin problems?
Please describe
Rows
Yes
No
Do you smoke?
Do you avoid the sun?
Do you avoid processed carbs?
Are you pregnant or trying?
Are you breastfeeding?
Have you ever had any of the following:
Rows
Yes
No
Botox or Dysport
Dermal Filler
Chemical Peel
Laser or IPL
Facial surgery
Other cosmetic procedures (please list)
How did you hear about us?
Are you concerned about?
Forehead Lines
Frown Lines
Crows Feet
Facial Hair
Body Hair
Lower Face Ageing
Lip Volume
Neck
Cheek Volume
Hands
Skin Quality
Scars
Other
Any other concerns?
Would you like us to inform you of our special offers via email from time to time? We do not share email addresses
Yes
No
If so please supply your email address?
example@example.com
Are you happy to receive a reminder text?
Yes
No
Mobile number
Are you happy to receive a follow-up phone call?
Yes
No
Are you happy to receive a follow-up text?
Yes
No
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