Lily Brow Bar Form || Lilys Beauty & Aesthetic

Name

Address

Post Code

Dob

Tel No.

Email

GP Name And Address

Do You Smoke ?

Do you Drink Alcohol?

Are You Pregnant or Breastfeeding

Do You Take Any of the following medications?

Laxatives/Vitamins E

Hormones/Cosmetics Pill

Steroids

Aspirin/analgesic Medication

St Johns Wart

Gentamicin/Neomycin

Anti-Coagulants

Do you have any allergies Yes/No please provide details if yes?

Heart Disease/angina

Thyroid Problems

Auto Immune disease

Arthritis

Asthma/bronchitis

Convulsions

Facial Cold Sores

Depression

High/Low Blood Pressure

Skin Disease

Stomuch Ulcers or Colitis

Glaucoma/Cataract

HIV/Hepatitis

Diabetes

Phelbitis

Bell's Palsy

Venereal Disease

Hypoglycaemia

Haemophiliac

Neuralgis

Asthma / COPD

Have You ever been admitted into hospital? Yes / No

Have you had any previous surgery both medical or cosmetic? Yes / No

Have you ever had botulinum treatment previously? Yes / No

Did this improve the appearance of lines?

Have you ever had dermal fillers before? Yes/No

Are you currently undergoing dental treatment? Yes / No

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? Yes/No

Patient Name

Date

if you have answeres yes to any of the above questions the practitioner it reserves the right to refuse any treatment if they treatment if they test you are unsuitable or request confirmation this is ok from your GP.

Lily Brow Bar Form

Lily Brow Bar Form

Do You Take Any of the following medications?

if you have answeres yes to any of the above questions the practitioner it reserves the right to refuse any treatment if they treatment if they test you are unsuitable or request confirmation this is ok from your GP.

Before submitting the form, please check in with the shop staff. Otherwise, you will need to refill the form.