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ReNu Aesthetic Consultation Form
To help me tailor your consultation and treatment safely and appropriately, I need a clear understanding of your medical history, previous treatments and aesthetic goals. Please answer the following questions as accurately as possible.
SECTION 1: About you
Section 1 of 9
Full Name
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First Name
Last Name
Date of Birth
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Please select a year
2026
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Mobile Number
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-
Area Code
Phone Number
E-mail Address
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example@example.com
Home Address
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Street Address
Street Address Line 2
City
County
Post Code
Emergency Contact (Please provide name, relationship to client and contact information)
*
GP Surgery / Address
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GP Surgery Phone Number
Where did you hear about us?
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Existing client
Friend / family recommendation
Instagram
Facebook
Google search
Google reviews
Website
Healthcare professional referral
Other
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SECTION 2: Medical History
Section 2 of 9
Do you currently have or have you ever had any of the following medical conditions? Please tick all that apply:
Heart disease
High blood pressure
Pacemaker or implanted electronic medical device
Fainting / vasovagal episodes
Stroke / TIA
Diabetes
Thyroid disorder
Autoimmune disease
Cancer
Bleeding disorder
Blood clot / DVT / PE
Migraines or severe light -triggered headaches
Epilepsy / seizures
Neurological disorder
Liver disease
Kidney Disease
Asthma
Severe allergies / anaphylaxis
Photosensitivity / light sensitivity
Cold sores / HSV
Rosacea
Eczema / psoriasis / other inflammatory skin conditions
Hyperpigmentation / melasma
Keloid or abnormal scarring
Anxiety / depression
Eating disorder
None of the above
Do you have any other medical condition, illness or injury that we should be aware of?
Yes
No
Please provide details.
Are you currently under the care of a hospital specialist or other medical professional, or have you had surgery or a hospital admission within the last 6 months?
Yes
No
Please provide details
Are you currently pregnant, breastfeeding or trying to conceive?
Yes
No
Not applicable
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SECTION 3: Medications & Allergies
Section 3 of 9
Are you currently taking or using any prescription medicines, over-the-counter medicines, supplements, creams, lotions, eye drops or other topical treatments?
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Yes
No
If yes, please list them below:
Do you have any known allergies or sensitivities
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No known allergies
Medication Allergy
Latex allergy
Adhesive / plaster allergy
Aspirin / salicylate allergy
Bee / wasp sting allergy
Other
Please provide details of any allergy or sensitivity, including the reaction you experience:
Do you carry an adrenaline auto-injector (EpiPen or equivalent)?
*
Yes
No
Not applicable
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SECTION 4: Hormonal & Lifestyle factors
Section 4 of 9
Which best describes your current hormonal status?
Regular menstrual cycles
Perimenopausal
Post-menopausal
Taking HRT
PCOS
Pregnancy related hormonal changes
Prefer not to say
Not applicable
Have you recently experience significant weight loss within the last 12-24 months?
Yes
No
If Yes, please provide further details if you are happy to do so
Do you smoke or vape?
Never
Previously
Occasionally
Daily
How regularly do you wear SPF / sunscreen on your face?
Daily
Most days
Occasionally
Only on holidays
Rarely / Never
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SECTION 5: Skin Health & Concerns
Section 5 of 9
What are your main skin or aesthetic concerns? Please tick all that apply
Fine lines / wrinkles
Skin laxity / sagging
Volume loss
Pigmentation / uneven skin tone
Redness / rosacea
Acne / breakouts
Acne scarring
Sensitive / reactive skin
Dryness / dehydration
Enlarged pores
Uneven texture
Dull skin
Facial thread veins
Dark circles / tired eyes
Jawline / lower face concerns
General skin rejuvenation
Prevention / healthy ageing
Skin tags / benign lesions
Unsure / would like guidance
Other
How would you describe your skin?
Dry
Oily
Combination
Sensitive / reactive
Unsure
How does your skin usually respond to sun exposure?
Always burns, never tans
Usually burns, tans minimally
Sometimes burns, gradually tans
Rarely burns, tans easily
Very rarely burns
Deeply pigmented skin
Does your skin regularly experience any of the following?
Redness
Flushing
Burning / stinging
Breakouts
Dryness
Tightness
Easy irritation
Pigmentation after spots or procedures
None of the above
Which skincare products do you currently use regularly?
Cleanser
Moisturiser
SPF
Vitamin C / antioxidant
Retinol / Retinoid
Exfoliating acids / AHA / BHA
Acne treatment
Pigmentation treatment
Growth factors / exosomes
Soap and water
None
Unsure
Have you taken isotretinoin (Roaccutane) within the last 6 months?
Yes
No
Unsure
If Yes, please provide the date you last took it.
Have you ever used a skincare product that caused a significant adverse reaction?
Yes
No
If Yes, please provide further details.
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Thermavein & Vascular Skin Assessment
Facial thread veins and persistent redness can sometimes be linked to underlying skin sensitivity, rosacea, inflammation or environmental factors. These questions help us better understand your skin behaviour and assess the most appropriate treatment approach for you.
Which areas are you most concerned about?
Around the nose
Cheeks
Chin
Forehead
Around the eyes
Neck / Chest
Legs / Body
General facial redness
Other
If other, please provide details
Approximately how long have you noticed these veins or redness?
less than 6 months
6-12 months
1-3 years
More than 3 years
Unsure
Do any of the following appear to worsen your redness, flushing or thread veins?
Heat
Sun exposure
Exercise
Alcohol
Stress / Anxiety
Hormonal changes
Spicy foods
Skincare products
Wind / cold weather
None that I have noticed
Have you ever been diagnosed with rosacea or sensitive / reactive skin?
Yes
No
Unsure
Have you previously had treatment for thread veins, redness or rosacea?
Yes
No
If yes: Please provide details
Do you have a history of pigmentation or prolonged skin marking after inflammation, spots or cosmetic procedures?
Yes
No
Unsure
Have you had significant recent sun exposure, used sunbeds, or are you planning significant sun exposure within the next 2 weeks?
Yes
No
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SECTION 6: Previous Aesthetic Treatments
Section 6 of 9
Have you previously had any of the following treatments?
Anti-wrinkle injections
Dermal filler
Skin boosters
Polynucleotides
Under-eye mesotherapy
Fat dissolving injections
Microneedling
Hydrafacial / hydrodermabraison
Microdermabrasion
Chemical peels
Laser / IPL
Radiofrequency treatments
Thermavein / thread vein treatment
LED phototherapy
Facial surgery
Other aesthetics treatment
None
Have you ever experienced a complication, unexpected reaction or poor outcome following an aesthetic treatment?
Yes
No
If yes, please provide details
When was your most recent aesthetic treatment
Within the last 7 days
Within last 2 weeks
Within the last month
Within the last 3 months
More than 3 months ago
Never
Are there any treatments or approaches you would prefer to avoid?
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SECTION 7: Your Goals
Section 7 of 9
What prompted you to book your consultation at this time?
What are you hoping to achieve from your consultation or treatment?
Which best describes your treatment goals?
Prevention / maintenance
Natural rejuvenation
Looking less tired
Improve skin quality
Improve skin health
Correct a specific concern
Improve facial balance / proportions
Improve confidence
Body contour concern
Unsure / would like guidance
How would you ideally like to feel following treatment? Please tick all that apply
More refreshed
More confident
More like myself
More comfortable without makeup
More comfortable in photographs
Healthier skin
Better informed about my skin / treatment options
Unsure and would like guidance
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SECTION 8: Communication & Photography
Section 8 of 9
Clinical photography forms an important part of your medical record and may be used to assess treatment progress. Do you consent to clinical photographs being taken and securely stored as part of your confidential clinical record?
*
Yes
No
Would you be happy to receive occasional information from ReNu Medical Aesthetics about treatments, skincare or clinic updates?
Yes
No
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SECTION 9: DECLARATION
Section 9 of 9
I confirm that the information I have provided is accurate and complete to the best of my knowledge.
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I Confirm
I understand that it is my responsibility to inform ReNu Medical Aesthetics of any changes to my health, medical conditions, medications, allergies, pregnancy/breastfeeding status or other relevant circumstances before treatment.
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I Understand
I understand that completing this questionnaire does not constitute consent to treatment.
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I Understand
I understand that any proposed treatment, expected benefits, risks, alternatives and aftercare will be discussed with me, and treatment-specific consent will be obtained separately in clinic before treatment is undertaken.
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I Understand
Do you have any important upcoming events, holidays or commitments that we should consider when planning treatment? Please provide details.
Electronic Signature
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