How did you hear about us?

*Denotes mandatory fields. Please provide as much information as possible, so we are able to contact you in case of emergency. To avoid confusion, kindly ensure your writing is legible. Tick as appropriate. Thank you.

Title

Surname

forenames

Date of Birth

age

gender

Address

Postcode

email

Mobile

Telephone

Occupation

Company

Next of Kin

Contact

Relationship

Do you suffer from any of the following? If yes please tick:

Heart complications

yesno

High Blood Pressure

yesno

Kidney Disease

yesno

Bleeding disorder

yesno

Diabetes

yesno

Cancer

yesno

General medical questions	Answer	Comment
Are you taking any medication?	selectyesno
Especially the following: Roacutanne - Coritisone, Blood thinners – aspirin, Immunosuppressive	selectyesno
Any allergies or are you allergic to any form of medication?	selectyesno
Especially the following: Latex - Face creams - Topical anesthetics, Nuts - Coritisone	selectyesno
Do you have any implanted medical devices such as a pacemaker or metal plates?	selectyesno
Do you have any heart or lung problems?	selectyesno
Do you suffer from any autoimmune disorders such as lupus?	selectyesno
Do you suffer from any mental health condition?	selectyesno
Do you have hepatitis B or C?	selectyesno

Contraindications/Cautions	Answer	Comment
Are you pregnant/breastfeeding?	selectyesno
Have you taken Roaccutane in the last 6 months?	selectyesno
Do you have epilepsy?	selectyesno
Do you have any history of keloid or hypertrophic scars?	selectyesno
Do you suffer from vitiligo?	selectyesno
Do you suffer from psoriasis or eczema on area wishing to have treatment?	selectyesno
Do you have any hormonal disorders?	selectyesno
Do you suffer from cold sores or herpes simplex?	selectyesno
Are you having any peels or microdermabrasion on area to be treated?	selectyesno
Have you had Botox or fillers on area to be treated?	selectyesno
Are you sun tanned at present?	selectyesno
Do you have excessively dry or sensitive skin?	selectyesno

GP’s Name:

Telephone:

Clinic’s Name & Address:

Do you want us to contact your GP?
yesno

The information that I have given, to the best of my knowledge, is correct.
I have not withheld any known medical information. I hereby consent to assessment and treatment.

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