Consultation Card

Client details

All form fields are required.

Gender

Confidential medical history questionnaire

Answer YES or No to the following questions; if YES, give more details below. If you do not understand a question please ask.


Are YOU

Attending/receiving treatment from a doctor, clinic, hospital or a specialist?

Taking medicines (tablets, creams, ointments, injections, birth control, etc.)?

Taking or haven taken steroids/cortisone in the past two years?

Allergic/Anaphylaxis to medicines (penicillin, etc.)?

Allergic to any materials (Elastoplast, latex, rubber, etc.)?

Pregnant or on IVF; or nursing/breastfeeding?

Due to start medical treatment I operation within the next 4 weeks?

Due to fly/travel within the next 2 days?


Have YOU

Had rheumatic fever or chorea?

Had jaundice, liver disease, or hepatitis A, B or C?

Any heart problems (previous heart attack, chest pains, heart murmur)?

Had blood tests for HIV or hepatitis?

Ever had your blood refused for a Blood Transfusion Service?

Had a bad reaction to general or local anaesthetic?

Any blood disorders (sickle cell anaemia, thalassaemia)?

Any blood clotting disorders (thrombosis, embolism)?

Ever been hospitalised? If 'yes', please specify when and what for in 'More Details' below.

Received any antibiotics in the last 3 weeks?

Had any operation in the last 4 weeks (especially facial surgery)?

Ever been diagnosed with Eaton Lambert Syndrome or Bell's Palsy?

Ever been diagnosed with any other long term medical condition?

Ever had Botulinum Toxin injected before and was there any problem?


Do YOU

Suffer from skin condition/disease(e.g. eczema, rosacea, psoriasis, etc)?

Suffer with muscle disorders (muscular dystrophy, multiple sclerosis, etc)?

Have a pacemaker or have you had any form of heart surgery or problems?

Suffer from asthma, hay fever, eczema or other allergies?

Suffer from any lung disease (emphysema, chronic bronchitis, etc)?

Suffer from any neurological disorders (epilepsy, myasthenia gravis)?

Suffer from any endocrine disorders (diabetes mellitus, thyroid disease, etc.)?

Suffer with fainting attacks, blackouts or giddiness?

Bruise easily or bleed excessively after tooth extraction, surgery or injury?

Suffer from kidney disease?

Suffer from any skeletal or joint disease (arthritis, scoliosis, kyphosis)?

Ever suffer from Dysphagia (difficulty in swallowing)?

Suffer from a needle or other phobia or faint easily?

1000

Cosmetic or Aesthetic treatments

Please provide all information regarding past cosmetic or aesthetic treatments (e.g. laser, micro-dermabrasion, derma-roller, etc.)




1000

Medical; Surgical; Social; Psychiatric; Occupational Problems or Plans

Please disclose any relevant information about Medical; Surgical; Social; Psychiatric; Occupational Problems or Plans.




1000

Treatment Consent

Treatment

Do we have your consent to take and keep photographs of you?

Do we have your consent to upload your pictures to Facebook?

Do we have your consent to upload your pictures to Instagram?

Declaration

Read this document carefully and if you agree that you have read the information leaflet: the therapist has explained everything about the above named procedure to your satisfaction; have checked that the information on this form and only if you approve and consent sign below.

  1. I authorise and consent to treatment for aesthetic effect and rejuvenation using the above procedure.
  2. I have been advised of the advantages and disadvantages associated with the above procedure and agree to go ahead.
  3. I understand that treatment experience and results with this procedure varies from client to client and as with all beauty therapy procedures, no guarantees can be made regarding the eventual outcome.
  4. I understand that the primary benefits are for personal aesthetic and rejuvenation effect and not for medical or essential health reasons.
  5. I am satisfied that I had enough 'cooling off' opportunity to enable me to make a rational and sober decision.
  6. I accept that the cosmetic improvements are secondary to a healthy lifestyle and sensible diet and that exercise regimes must be maintained.
  7. I have been given sufficient opportunities to ask questions and seek further information and have received satisfactory answers to all of them.
  8. I accept although rare, that adverse outcomes such as pain. bleeding, bruising, infection, numbness, scaring and lumps may occur, and that some scars or lumps may be permanent
  9. I am aware that with relatively new procedures, there are no long term studies on adverse effects and complications.
  10. I consent to the use of topical or local anesthesia if required.
  11. I authorise the taking of photographs and understand that these photographs cannot be displayed without my consent.
  12. I understand that I receive this optional treatment (which Is not necessary or life saving) from Independent private therapists who are not affiliated with NHS or Public Agencies in the UK.
  13. I give my consent that in the unlikely event of a 'needle stick injury" to the Therapist, my blood can be tested for any blood borne transmissible disease.
  14. I hereby indemnify and hold harmless, the treating therapist & clinic where the procedure was done from any liability, damages, cost and expenses arising from or out of the NPR treatment.
  15. I understand that I can refuse treatment at any time; and may ask to have a relative, friend or another therapist present during the procedure.
  16. I understand that it is my right and responsibility to ask further questions if anything is unclear.
  17. I understand that a chaperone can be present or I can discontinue proceedings at any time.
  18. I confirm that I have been given sufficient information to understand the treatment and the products used, including contraindications and adverse effects as well as off-license usage.
  19. I consent to you keeping a copy of this document on record/computer.
  20. I have read the INFORMATION & RISK (WHAT TO EXPECT) leaflet/booklet.

A client has a legal right to grant of withhold consent prior to examination or treatment. It may be withdrawn at any time. Clients should be given sufficient information to comprehend the proposed treatment, adverse effects and possible alternatives as fully as possible. Consent should be recorded on this form.