Consultation Form

Company

Please read and complete
I can confirm that the data you provide will not be shared with anyone other than my Prescriber if it requires to be depending on the treatment that you book in for, I can also confirm that this will be protected by the GDPR Act 2018

What Aesthetic Treatment(s) are you looking to book?

Anti wrinkle Treatment

Lip filler

Cheek filler

Jawline filler

Chin filler

Non surgical Rhinoplasty

Vitamin B12

Derma planing

PRP Treatment

Bio Gel Filler

Fat dissolving

Meso Therapy

Microneedling

PDO threads

PDO Cogs

Marionette lines

Nasolabial

Vampire Facial

Carboxy Therapy

Microdermabrasion

Steam Facial

LED Facial

Brow Wax

Brow tint

Classic lashes

Hybrid lashes

Lash lift and tint

Spray Tan

Million Dollar Facial

Hopi Ear candles

Pedicure

Gel toes

Intimate Waxing

Underarm waxing

Leg wax

Chin wax

Top lip wax

Arm wax

Microsceelotherapy

Meso -Tox

V- LIft

Brow lamination

Henna Brows

Have you or your family recently suffered with Covid 19? *

Yes No

Have you had a Covid Vaccine? *

Yes No

Date received or booked covid test? *

I can confirm that I am the individual completing this Consultation form and the information I give is correct? *

Yes No

Full Name *

Date of Birth *

Email Address *

Full Address *

Contact Telephone number *

Are you currently pregnant or breastfeeding?

Yes No

Have you had had a history of severe allergy/anaphylaxis?

Yes No

Are you currently having any aesthetics treatments (eg. laser, peels, dermabrasion etc.) If yes, please give me more details:

Yes No Other:

Have you ever suffered with auto-immune disease or any disease affecting the immune system?

Yes No

Have you had any treatment with dermal fillers, absorbable dermal fillers, semi-permanent dermal fillers or botulinum toxin? If yes which treatment did you receive, what areas were treated and when?

Yes No

Do you have any cutaneous (skin) infection or inflammatory problems (eg. herpes (cold sores), acne etc.)

Yes No

Are you taking any steroids, aspirin or anticoagulant (eg. warfarin, apixaban, rivaroxaban etc.)

Yes No

Do you suffer from acute rheumatic fever or recurrent sore throat?

Yes No

Do you suffer from any allergies, in particular allergies to hyaluronic acid, amide type local anaesthetics or lidocaine?

Yes No

Do you suffer from untreated epilepsy?

Yes No

Do you tend to develop hypertropic scarring?

Yes No

Do you suffer from cardiac conduction disorders (heart rhythm problems etc.) If yes, please provide details.

Yes No

I confirm I have been informed that: The range of products are injected into the dermis to correct wrinkles, folds aneli of the face and skin or for the lip augmentation. You should be aware that combining the range with certain drugs that reduce or inhibit hepatic metabolism is advisable. You should be made aware that this product contains 0.3% of lidocaine that may produce a positive result in anti-doping tests. Due to the use of a needle, there is likely to be some bleeding in the injection site. This reaction may last for several days. Rarely discolouration of the injection site, necrosis, abscess formation granulomas, hypersensivity and haematomas have been reported. Indurations or nodules may develop at the injection site. If any of these symptoms persist for more than one week, or if any other side effects develop, please report them to the practitioner as soon as possible so that they can advise on the best course of treatment. Although rare, such side effects and their treatments may last for several months. The aesthetic effects of the product range, lasts for up to 12 months but will vary depending on the condition of the skin, area treated, amount of product injected, injection technique and lifestyle factors such as sun exposure and smoking. The average life of treatment in the lips is less than other areas because of the high vascularisation and action in the lip area. A touch up procedure may be required 1-3 weeks after the first injection and helps to optimise the results. After treatment, please avoid extreme facial expressions, alcohol consumption and applying makeup for 12 hours. Please also avoid extreme sun exposure, UV light, freezing temperatures and saunas for 2 weeks after treatment. My treating healthcare professional/aesthetic medical practitioner has: Provided me with sufficient information about the treatment detailed overleaf in order to make an informed decision. Given me the opportunity to ask all remaining questions I may have about the treatment and has answered to the best of their ability. Given me the time to consider the treatment detailed overleaf. Received the relevant medical history information from me to the best of my knowledge. I therefore consent to receiving the described treatment by my treating healthcare professional/aesthetics medical practitioner.

Yes No

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