Medical history declaration. – Angels Twelve | Aesthetics Beauty Hair

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Medical history declaration.

New Patient medical history declaration. Please complete the following suitability for treatment form. Once completed don't forget to sign before submitting. Many thanks. Angels Twelve | Professional Aesthetics.

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Name *

First

Last

from provide you

Please select how you heard about us?

Medical History.

Please complete the required medical history screening questions.

Are you receiving treatment from doctor, hospital or specialist? *

No
Yes

Are you taking any medicines, supplements,topical creams or inhalers? *

No
Yes

Are you allergic to local anaesthetics, do you have a history of anaphylactic shock (severe allergic reactions)? *

No
Yes

Do you suffer from any other known allergies? *

No
Yes

If you have answered 'Yes' to the above please provide details below.

Are you taking Aspirin, Warfarin, other anti-coagulant treatments or any other medication or dietary supplements such as Omega-3 that can affect platelet function and bleeding time? *

No
Yes

10 Do you suffer from any illnesses e.g. diabetes, angina, epilepsy, hepatitis, auto immune disease? *

No
Yes

Are you taking / receiving steroids, chemotherapy, radiotherapy? *

No
Yes

Are you using topical retinoid’s / vitamin A products? *

No
Yes

Have you taken oral retinoid’s (Roaccutane) in the past 12 months? *

No
Yes

Do you suffer from keloid scars? *

No
Yes

Do you bruise easily? *

No
Yes

Are you a smoker? *

No
Yes

I am interested in (you may tick more than one) *

Anti-wrinkle injections
Dermal (Cheek, chin and lip) fillers
Medical grade Skin Peels
PDO tread lifts (non-surgical face lift)
Carboxy therapy
IV Vitamin infusions
Facial fat dissolving injections
Plasma pen

I hereby confirm that *

I acknowledge that no written or implied verbal guarantee, warranty, or assurance has been made to me regarding the outcome any aesthetic/ beauty procedure.
I confirm that to the best of my knowledge that the information that I have supplied is correct and that there is no other medical information I need to disclose.
I am not pregnant nor actively breastfeeding.

Signature | Please sign the form and when you are ready click 'submit'. *

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Date *

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