Medical Consultation Form Please complete prior to your appointment or if you have any changes in your medical status. Name(Required) First Last Date of Birth(Required) DD slash MM slash YYYY Email(Required) Address(Required) Street Address Suburb Todays date(Required) DD slash MM slash YYYY Emergency Contact name and phone number: Name & Phone: IMPORTANT - Do you have a history of:Please tick any which apply: Untreated Epilepsy Any allergy or anaphylaxis Allergy to lidocaine (anaesthetic) Prophyria (enzyme disorder) Neurological disorder Muscular Weakness (eg myasthenia gravis, Eaton Lambert Syndrome) Infection in our facial area Currently taking aminoglycoside antibiotics? Any autoimmune disorders? Had a permanent filler eg aquamid, silicone etc? Had vaccination within the last 2 weeks, or intend to have one in the upcoming 2 weeks? Blood relatives had blood clots? Do you get cold sores? Taken any Roaccutane, Accutane or isooctane in the last 6 months? Prone to keloid/raised scarring? Do you smoke? Do you drink alcohol? Do you exercise regularly? Do you get migranes? Do you suffer from excessive bleeding or bruising? Abnormal skin pigmentation or vitiligo? Skin cancer or suspicious moles? Facial or dental implants? Pregnant or planning on it in the next 3 months? Are you currently breastfeeding? Planned travel in the next 7 days? Recent procedure/s (dental or medical)? Planning any procedure/s (dental or medical) in the near future? Antibiotics recently? Any recent infections? Anxiety/Depression? Any other mental health issues? If YES to ANY of the above, please provide details:Please list any REGULAR MEDICATIONS or HERBAL SUPPLEMENTS/VITAMINS you are currently taking (including any neurological medications or blood thinners ie. Warfarin, St Johns Wort or Fish oil).Do you have ANY other medical conditions or things you feel are potentially relevant to you proceeding with treatment?Please detail ANY previous cosmetic treatment you have had and whether you were happy with the outcome (if you have not had a previous cosmetic treatment please write N/A).(Required)Please detail your current skincare regime:(Required)Please specify what you wish to discuss or have treated?(Required) Δ
