HEALTH QUESTIONNAIRE
E-mail*
First Name*
Last Name*
Mobile Number*
Address*
Postcode*
DOB
Do you smoke?*
If “YES", how long have you smoked for? How much do you smoke per day?
Do you drink Alcohol?*
If “YES”, approximately how many units per week?
Are you pregnant?*
Are you breastfeeding?*
Are you trying to lose weight?*
Are you currently taking or have you ever taken any of the following medications? (please tick all that apply)
If “YES" please give details of medications you are taking:
Do you suffer from any allergies, particularly to hyaluronic acid or local anaesthetics or lidocaine?*
If “YES” please give allergy details:
Do you suffer from any of the following? (please tick all that apply)
If “YES” please give details:
Have you ever been admitted to Hospital?*
If “YES” please give details:
Have you had any previous surgery (non-cosmetic)?*
If “YES” please give details:
Have you had any Botulinum Toxin, Dermal Fillers, Sunbed, Dermabrasion, Skin Peels or Laser Skin Resurfacing treatments in the last 6 weeks?*
If “YES” please give details:
Do you suffer from a bleeding disorder?*
Have you been tested positive with COVID 19?*
Have you mixed with any one who has tested positive with COVID 19 in the last 14 days?*
Have you had any of the following new symptoms in the last 7 days?* (please tick all that apply)
Have you received Coronavirus (COVID-19) vaccine?*
If YES when did you receive COVID-19 vaccine? (dose 1 or 2 - whichever is the latest)
Your Signature*
Date Signed
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Мы работаем по предоплате £50. Эта сумма входит в стоимость консультации или процедуры.
Все консультации проводит лично Eliza Ridvanska
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