Collagen Lift Consultation
Medical Questionnaire
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
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Major Contra-indictions
Kidney/Liver Disease
Heart Conditions Inc. Pacemaker
Auto-Immune Diseases
Diabetes
Immuno-suppressed individuals
Chronic respiratory failure
Cerebral Palsy
Inflammation or infection
Abnormal Swelling/Oedema
History of Keloid Scarring or Abnormal wound healing
Inability to communicate
Benign or Malignant Tumours
Arteriosclerosis obliterans
Pregnancy
Cancer Inc. Radiation/Chemotherapy
Minor Contra-indictions
Psoriasis or Eczema
Areas of Sensory Impairment
Areas of dry or fragile skin
Herpes (Shingles/Cold Sores)
Bruises/Abrasions/Wounds
Active Acne
Moles or Skin tags
Metal pins/plates
Varicose Veins
Recent Surgical Procedures - 6 months
Any other medical conditions?
If answered YES, please give full details;
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Are you taking any Medication or Recreational Drugs?
Yes
No
Are you currently or have used Roaccutane, Isotretinions, Retin A?
Yes
No
Please give details if you answered YES to the above questions;
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Have you had any treatments in the past 6 months?
Chemical Peels
Injectable Fillers
Botox
If YES, what date did you have treatment and areas?
Have you had any treatments in the past 4 weeks?
Microdermabrasion
Dermaplaning
Permanent Makeup
Electrolysis
IPL/Laser
Microneedling
Other
If YES, what date was your last treatment and areas?
What would you say are your concerns?
Wrinkles
Skin laxity
Acne scarring
Cellulite
Stretch marks
Other
Areas you are looking to improve with the Collagen Lift
Full Face
Eyes
Jowls
Neck
Abdomen
Hips
Upper arms
Buttocks
Thighs
Do you have any concerns or questions regarding Collagen Lift?
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Consent Form - Please Tick to Confirm
I understand I must notify my therapist of any adverse reactions
I am aware the possible side effects of treatment can be redness and warmth, and expected to be temporary. Any reactions lasting more than 72 hours should be reported.
I understand not everyone is a successful candidate for this treatment and results may vary.
I believe I have adequate knowledge upon which to base an informed consent.
I affirm that all information provided by me is correct to the best of my knowledge
I authorise before, during and after photos to be taken for my patient profile
I agree for Hayley and Skinbase to utilise my treatment photos for advertising purposes.
I agree to adhere to all post treatment advice and agree to follow these guidelines at all times during the treatment programme
I agree that no refunds will be given for treatments recieved. I understand and agree that all services rendered to me are charged directly to me and I am personally responsible for payment.
Signature
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