Complete and submit your Medical Questionnaire

Fill in this form before you attend your appointment, It will allow our Doctors and Nurse Prescribers to view your medical history prior to meeting you. This may save time, as in some cases we may need to ask you for more information or to bring your medicines with you. If we find you are unsuitable for treatment we may be able to save you a long journey.

 

 

 

Please Sign In
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Personal Details
Family History
General Medical History
  • Have you had Botox, Visable, or Dysport before?
  • Was the treatment satisfactory?
  • Were there any medical complication with the treatment?
  • Have you been to see a GP, Doctor, Nurse, Dentist, or Pharmasist
  • Are you currently taking any medication, Either on prescription or otherwise?
Medical History Precautions
  • Is there any posibility that you are pregnant?
  • Are you breast feeding?
  • Have you recently been treated with any other dermal filler / cosmetic injection on your face?
  • Do you have any permanent implant(s)
  • Have you undergone laser skin resurfacing or recieved a skin peel in the past 6 weeks?
  • Do you suffer from facial herpes simplex or have any active skin conditions, e.g. Acne or psoriasis?
  • Do you have or have you ever had a form of skin cancer?
Medical History Considerations
  • Have you previously been treated with Restylane, Perlane, Restylane Touch, Restylane Vital, Restylane Lipp, and shown hypersensitivity?
  • Have you recieved a Roaccutane treatment in the past 12 months?
  • Do you suffer from any known allergies?
  • Do you have any history anaphylactic shock (severe allergic reactions)?
  • Are you taking asprin, steroids, or anticoagulants?
  • Are you currently taking any other medication?
  • Do you suffer from any illness, e.g. Angina, epilepsy, diabetes, HIV positive, hepatitis, auto immune disease (e.g. Rheumatoid arthritis), depression, stress?
  • Have you recently gone under major surgery?
  • Are you currently undergoing dental surgery?
  • Do you suffer from fainting or low blood pressure?
  • Do you suffer from keloid or hypertrophic scarring?
  • Do you have a needle phobia?
  • Are you prone to bruising?
  • Have you recently been exposed to the sun or sun beds?
Treatments
  • What area of your upper face are you considering having treated?

  • What area of your lower face are you considering having treated?

  • What products are you considering?

Final Comments
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