Non-Surgical Form

Title:

Street Address:

Address Line 2:

City:

Post Code:

Country:

Gender:

Age:

Name:

Relationship:

Contact Number:

Are you happy for this person to be contacted about your treatment?*:

Are you registered with a GP?

Name of GP & Practice:

Full Address:

Contact number:

1) Occupation:

2) Do you smoke:

3) How many do you smoke a day?

4) Do you drink alcohol?

5) Units per week - A medium glass of wine is 2 units; a single spirit measure is 1 unit and a pint of beer is 2-3 units:

8) Do you take regular exercise?

If yes, what exercise?

9) Do you follow a special diet?

9a) Please state your current diet:

10) Are you currently pregnant or breast feeding?

11) Are you trying to conceive or undergoing IVF treatment?

13) Pigment disorders?*:

14) Increased scar formation?*:

15) Increased light sensitivity?*:

16) Skin Cancer?*:

17) Keloid scarring? (lumpy overgrowth of scar tissue)*:

18) Acne, psoriasis or any other active skin condition or infection in the area(s) you wish to have treated?*:

19) Amyotropic lateral sclerosis (ALS)?*:

20) Myasthenia gravis, Eaton-Lambert syndrome, amyotrophic lateral sclerosis, multiple sclerosis?*:

21) Impaired ability to swallow or dysphagia?*:

22) Angina, cardiac infarction?*:

23) High/low blood pressure?*:

24) Emotional or neurological disorders, e.g. seizures (epilepsy), paralyses, depression, M.E. (Myalgic Encephalomyelitis)?*:

25) Migraines?*:

26) Bell's palsy or a stroke?*:

27) Glaucoma?*:

28) Asthma?*:

29) Diabetes?*:

30) Thyroid problems?*:

31) HIV, hepatitis, rheumatoid arthritis or other auto-immune diseases?*:

32) Nosebleeds, bruises (e.g. after a light touch) or coagulation disorders or bleeding disorders?*:

33) Do you or does anyone in your family suffer from a hereditary disease?*:

33a) If so, to/what?*:

34) Do you have any allergies or hypersensitivities? E.g. Hay fever, asthma, hypersensitivity (e.g. to collagen-containing products, lidocaine, painkillers, anaesthetics, foods, medications, plasters, latex)?*:

34a) If so, to/what?*:

35) Have you ever been in hospital with a severe allergic reaction?*:

35a) If so, to/what?*:

36) Are you currently undergoing any desensitisation treatment?*:

36a) If so, to/what?*:

37) Have you recently taken any medication or are you currently taking medication? Including painkillers, coagulation inhibitors, antibiotics, steroids, muscle relaxants (e.g. aspirin, warfarin, ibuprofen) or herbal preparations, vitamins and supplements.*:

37a) Please state:*:

38) Have you taken Roaccutane or isotretinoin (for acne) in the past 12 months?*:

If yes, please expand:

39) Have you had any recent immunisations?*:

39a) Please state:*:

40) Have you had any major surgery in the last six weeks?*:

40a) Please state:*:

41) Are you planning or currently undergoing dental treatment?*:

If yes, please expand:

42) Have you previously undergone operations in your facial area (e.g. laser, skin peel, facelift, IPL skin resurfacing, plastic surgery, injury, etc)?*:

42a) Please state:*:

43) Do you have a phobia about blood or needles?*:

44) Are you prone to bruising?*:

45) Have you recently been on a sunbed?*:

45a) Please state when you last went on a sunbed:*:

46) Have you received local anaesthetic injections at your dental practice?*:

47) Any problems with local anaesthetic injections at your dentist?*:

If yes, please expand:

48) Have you received Botox type injections previously?*:

48a) How long ago?*:

49) Did you experience any side effects or allergic reactions?*:

49a) Please state:*:

50) Have you received dermal filler injections previously?*:

50a) How long ago? Please also state the name of the filler used if possible:*:

51) Do you have permanent implants in your face?*:

51a) Please state:*:

52) Did you experience any side effects or allergic reactions?*:

53) Do you have or previously had any other medical condition not mentioned above?*:

53a) Please state:*:

54) Do you feel this treatment will help you improve your sense of well-being, your self confidence, your psychological, emotional and overall health?*:

55) Which aspects of your appearance are you concerned about and what are your expectations about the outcome of treatment?

56) Do you have any worries or concerns about treatments or anything else that you wish to tell us?

The use of and indications of the products I will be treated with have been explained to me by my practitioner and I have had the opportunity to have all questions answered to my satisfaction. I have been specifically informed of the following: after the treatment some common injection related reactions might occur. These reactions are generally described as mild to moderate and typically resolve spontaneously a few days after treatment. These reactions are normal and are to be expected.*: