test

    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

    High Blood Pressure

    Kidney Disease

    Bleeding disorder

    Diabetes

    Cancer

    General medical questions Answer Comment
    Are you taking any medication?

    Especially the following: Roacutanne - Coritisone, Blood thinners – aspirin, Immunosuppressive
    Any allergies or are you allergic to any form of medication?
    Especially the following: Latex - Face creams - Topical anesthetics, Nuts - Coritisone
    Do you have any implanted medical devices such as a pacemaker or metal plates?
    Do you have any heart or lung problems?
    Do you suffer from any autoimmune disorders such as lupus?
    Do you suffer from any mental health condition?
    Do you have hepatitis B or C?
    Contraindications/Cautions Answer Comment
    Are you pregnant/breastfeeding?
    Have you taken Roaccutane in the last 6 months?
    Do you have epilepsy?
    Do you have any history of keloid or hypertrophic scars?
    Do you suffer from vitiligo?
    Do you suffer from psoriasis or eczema on area wishing to have treatment?
    Do you have any hormonal disorders?
    Do you suffer from cold sores or herpes simplex?
    Are you having any peels or microdermabrasion on area to be treated?
    Have you had Botox or fillers on area to be treated?
    Are you sun tanned at present?
    Do you have excessively dry or sensitive skin?

    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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