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Fibrovein form

What is you first name?

What is your surname?

What is your date of birth?

Address

Postcode

Email address

Mobile number

Are you currently taking any medications, including the oral contraceptive pill?

Yes

No

If you answered yes to medications, what are they?

Do you suffer from any of the following?

Uncontrolled diabetes meleatus

Toxic Hyperthyroidism

Tuberculosis

Asthma

Migraines

Neoplasms

Sepsis

Blood Dyscrasias

Acute Respiratory Disease

Acute Skin Disease

None of the above

Do you have any allergies?

Do you smoke, if so how many a day?

Do you drink alcohol, if so how many units weekly?

What is your height?

What is your weight?

Have you ever suffered with a Deep Vein Thrombosis (DVT) and when?

Do you have any family history of vein disease?

Have you ever suffered with Thrombophlebitis and when?

Are you currently immobile?

Yes

No

Are you currently pregnant or breastfeeding?

Yes

No

Have you/or currently undertaking any radio/chemotherapy?

Yes

No

Have you ever been admitted to hospital or had any surgeries?

Yes

No

If yes to the above, what and when?

Have you had any previous vein treatments in the past?

Yes

No

If yes, when?

Do you have any long haul flights booked in the next month?

Yes

No

Where are the veins that require treatment?

Do you know how you came to have these veins?

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- - Skin Boosters
  - Light Eyes
  - Profhilo
  - Jalupro
  - INFINI
  - Sunekos
  - Sculptra
  - Luminera Hydral
  - Ejal 40
  - Nucleofill
  - Sosum Skin Booster
  - Toskani
  - Chemical Peels
  - Chemical Peels
  - PDO Threads
  - PDO Threads
  - Fat Dissolvers
  - Deso face & body
  - Lipolab
  - lipolax
  - Aqualyx
  - celluerase
  - Strikecell
  - Serums
  - Mesotherapy Products
  - Packages
  - Skincare Products and Vitamins
  - Machines and Devices
Training Courses
- - My Aesthetic Book!!
Contact Us
Blog

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