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Our Story
Clinics
Information
Safety
Booking Procedure
Consent Form
Pre & Post Care
FAQs
Terms & Conditions
Shop
Products
My Cart
Checkout
Contact
Our Story
Clinics
Information
Safety
Booking Procedure
Consent Form
Pre & Post Care
FAQs
Terms & Conditions
Shop
Products
My Cart
Checkout
Contact
Our Story
Clinics
Information
Safety
Booking Procedure
Consent Form
Pre & Post Care
FAQs
Terms & Conditions
Shop
Products
My Cart
Checkout
Contact
Book a Consultation
Pay Consultation Fee
Consent Form
Patient Consent Form & Information Sheets
Patient Information Sheets
Antiwrinkle
Dermal Filler
Fat Dissolver
Collagen Stimulator
Before your procedure, please ensure you have filled our the consent form below.
Step
1
of
2
- Patient Details
50%
Patient Details
Given Name
*
Surname
*
Pronouns or Gender
*
Date of Birth
*
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Residential Address
*
Street Address
Suburb
State
Postcode
Mobile Number
*
Email
*
Medical History
Do you have any allergies (medication / food / insects / other)?
*
If yes, please list below
Yes
No
Allergies
Do you have any medical conditions, including thyroid problems, bleeding disorders, auto-immune disorders or neuro- muscular conditions? (e.g. hypothyroidism / haemophilia / myasthenia gravis)
*
If yes, please list below
Yes
No
Medical Conditions
Do you have any scarring on your face caused by an operation, procedure or traumatic injury? (e.g. facelift / rhinoplasty / skin cancer / car accident / childhood injury)
*
If yes, please list below
Yes
No
Facial Surgery or Injury
Do you experience coloured or raised scarring if your skin is cut or injured?
*
If yes, please list below
Yes
No
Hypertrophic or Keloid Scars)?
Have you been given local anaesthetic before? (e.g. excision of mole or tooth extraction)
*
Yes
No
Do you take any medications or health supplements? (e.g. blood thinners / aspirin / ibuprofen / fish oil)
*
If yes, please list below
Yes
No
Medications or Supplements
Are you currently pregnant or breast feeding or considering either of these in the next 3 months?
*
Yes
No
Have you received any vaccinations in the previous 4 weeks?
*
Yes
No
Are you having any dental treatments in the 2 weeks either side of your injectable treatment?
*
Yes
No
Have you had any infection, including sinus condition or dental health issue in the last few weeks?
*
If yes, please list below
Yes
No
Sinus conditions, dental health issues or infections
Are you planning any international travel in the next 2 weeks?
*
Yes
No
Have you ever received antiwrinkle treatments with botulinum toxin type-a? (e.g. Botox / Dysport / Xeomin)
*
(botox / dysport / xeomin)
Yes
No
Last treatment date with botulinum toxin type A
Areas treated with botulinum toxin type A
Have you ever received treatment with dermal fillers or collagen stimulators before? (e.g. Restylane / Juvederm / Aquamid / Sculptra / Radiesse etc)
*
Yes
No
Last treatment date with dermal fillers
Areas treated with dermal fillers
Have you ever received treatment with a fat dissolver? (e.g. Lipodissolve / Belkyra / PCDC / Deoxycholic acid)
*
Yes
No
Last treatment date with a fat dissolver
Areas treated with a fat dissolver
Have you experienced any side effects or ‘bad results’ from any previous cosmetic treatments?
*
If yes, please list below
Yes
No
Side effects or ‘bad results’
Do you smoke or vape?
*
Yes
No
Have you ever had a cold sore ?
*
Yes
No
Are you worried about aspects of how you look?
*
Yes
No
If you answered 'Yes' – Do you think about these things a lot and wish you could think about them less?*
Yes
No
Patient declaration
*
I, the patient, declare that all information provided to answer these questions is true to my knowledge.
Name (patient)
*
Signature (patient)
*
Signed Date
*
DD slash MM slash YYYY
