Azzalure Consultation form

     

    Personal information (to be completed by client)

    NAME
    SURNAME
    DATE OF BIRTH
    ADDRESS
    POSTCODE
    TELEPHONE (M)
    EMAIL ADDRESS
    GP NAME
    GP ADDRESS
    GP POSTCODE
    How did you hear about us?
    How did you hear about us? Other:
    Referred by someone? (Name the person who referred you):
    Is this your first visit?
    How many times you’ve used our services?
    Would you like to hear about our offers?
    Preferred method of contact:

     

    Patient information Answer Comment
    Do you smoke? If ‘Yes’, how many per day?:
    Do you drink alcohol? If ‘Yes’ how many units per week?
    Are you Pregnant or is there a possibility that you are pregnant?
    Are you Breastfeeding?

     

    Are you currently taking or have you ever taken any of the following medications? Answer Comment
    Laxatives/Vitamin E
    Hormones / Contraceptive pill
    Steroids/gold injections
    Aspirin/pain killers
    St John’s Wort
    Gentamicin/Neomycin
    Roaccutane
    Anti-coagulants
    If ‘Yes’, please give details or list any other medication you are taking
    Do you suffer from any known allergies? If ‘Yes’, please give details:
    Do you have a history of anaphylactic shock (severe allergic reactions)? If ‘Yes’, please give details:

     

    Have you suffered from any of the following? Answer Comment
    Heart disease/angina
    Auto-immune disease
    Asthma/bronchitis
    Facial cold sores
    High/low blood pressure
    Stomach ulcer/colitis
    HIV/hepatitis
    Venereal disease
    Phlebitis
    Thyroid problems
    Arthritis
    Convulsions
    Depression
    Diabetes
    Hypoglycaemia
    Glaucoma/cataract
    Bell’s/facial palsy
    Keloid or hypertrophic scarring
    Do you suffer from facial herpes simplex or have any skin conditions, e.g acne or psoriasis? If ‘Yes’, please give details:
    Do you have or have you ever had any form of skin cancer? If ‘Yes’, please give details and dates:
    Have you ever been admitted to hospital? If ‘Yes’, please give details:
    Have you had any previous surgery (non-cosmetic)? If ‘Yes’, please give details:
    Have you previously had any cosmetic surgery, including eye/eyelid or facial surgery? If ‘Yes’, please give details and dates:
    Have you had botulinum toxin treatment before? If ‘Yes’, what was treated and when?
    Did botulinum toxin treatment significantly improve your lines?
    Have you had dermal fillers before? If ‘Yes’, please give details and dates:
    Have you had any sun bed treatment, dermabrasion, skin peels or laser skin resurfacing in the last 6 weeks? If ‘Yes’, please give details and dates:
    Have you ever experienced any hypersensitivity to lidocaine (a local anesthetic?) If ‘Yes’, please give details and dates:
    Do you have any permanent implant(s) at the site(s) to be treated? If ‘Yes’, please give details and dates:
    Are you currently undergoing any dental treatment? If ‘Yes’, please give details and dates:
    Do you have any phobias that may affect treatment? e.g. needles or blood - If ‘Yes’, please give details:
    Are you particularly prone to fainting, bruising, keloid scarring or bleeding?
    Any other medical problems?

     

    What are your expectations of the outcome of the treatment?

     

    IF YOU ANSWERED ‘YES’ TO ANY OF THE QUESTIONS, YOUR PRACTITIONER MAY ASK YOU FOR MORE DETAILS TO DECIDE IF YOU ARE SUITABLE FOR TREATMENT.

     

    Patient Signature: 
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    Date:

     

    Client Signature