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Anti-Wrinkle Injection and Cosmetic Procedure
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Anti-Wrinkle Injection and Cosmetic Procedure
Anti-Wrinkle Injection and Cosmetic Procedure
Name
Address
Postcode
DOB
Tel
GP Name And Address
Do you smoke ( if yes how many per day )
Do you Drink Alcohol ( if yes how many units per day )
Are you pregnant or brestfeeding
Select
Yes
No
Do you take any of the following medictions?
Laxatives/Vitamins E
Select
Yes
No
Hormones/Cosmetics Pill
Select
Yes
No
Steroids
Select
Yes
No
Aspirin / analgesic medication
Select
Yes
No
St Johns Wart
Select
Yes
No
Gentamicin/Neomycin
Select
Yes
No
Anti-Coagulants
Select
Yes
No
Do you have any allergies Yes / No please provide details if yes?
Heart disease/angina
Select
Yes
No
Thyroid Problems
Select
Yes
No
Auto immune disease
Select
Yes
No
Arthritis
Select
Yes
No
Asthma/bronchitis
Select
Yes
No
Convulsions
Select
Yes
No
Facial cold sores
Select
Yes
No
Depression
Select
Yes
No
High/Low blood pressure
Select
Yes
No
Skin Disease
Select
Yes
No
Stomach ulcers or colitis
Select
Yes
No
Glaucoma/cataract
Select
Yes
No
HIV/Hepatitis
Select
Yes
No
Diabetes
Select
Yes
No
Phelbitis
Select
Yes
No
Bell's palsy
Select
Yes
No
Venereal Disease
Select
Yes
No
Hypoglycaemia
Select
Yes
No
Haemophiliac
Select
Yes
No
neuralgis
Select
Yes
No
Have you ever been admitted into hospital?
Have you had any previous surgery both medical or cosmetic?
Have you ever had botulinum Treatment previously?
Have you ever had dermal fillers before?
Are you currently undergoing dental treatment?
Are there any area/phobias you fell you need to advise your practitioner of prior to treatment? E.g., needles/blood
Are you prone to fainting, bruising, or bleeding?
Patient Name
Client Signature
Clear Signature
Date
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