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Toxin-consultation-form

START - This form is for you to keep records of all your consultations, in order to keep them safe and secure. This form is to aid you whilst you do your face2face consultation, it is not a replacement.

patients surname

patients forename

patients Address (line 1)

patients Address (line 2)

patients Town / City

patients County

patients Post Code

patients Date of Birth

patients Email address (Must be of the patient)

patients Mobile number

Have you had this treatment before?

Yes

No

If you did have it before, did it work well?

Yes

No

First time I am trying it

Which areas do you want injecting?

Forehead

Outer eye

Eyebrow lift

Hyperhydrosis

Do you have any medical conditions?

Yes

No

If yes to medical conditions, which medical conditions do you have?

Are you currently taking any over the counter or prescribed medicine?

Yes (please list them below)

No

Do you have any of the following medical conditions?

Bell's Palsy

Any muscle disorders

myasthenia gravis

eaton lambert syndrome

None of the above

If yes, what medicine are you taking?

Do you suffer from any allergies?

No

Yes (Please list your allergies below)

If yes, what allergies do you suffer from?

Please note; if you have egg allergies you should avoid this injection, as it contains traces of egg.

Are you under the hospital treatment for anything?

Yes

No

Are you pregnant or breastfeeding?

Yes

No

Is your skin generally clear, e.g. ACNE

Yes my skin is clear

I suffer from mild ACNE

My skin suffers from Moderate / Severe ACNE

What is the name of your aesthetics practitioner ( person that will be injecting you )

Please confirm you have read the after care advice

Avoid sunbeds before treatment

Don't exercise 4-6 hours after the procedure

Don't lie down 4-6 hours after the procedure

Face to Face consultation date

Please fill out the details below of the Aesthetics Practitioner. And the delivery address of the aesthetics practitioner.

FINISH

MENU
Pharmacy Sign Up
Pharmacy Shop
Shop
- - 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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