Name * First Name Last Name Date of Birth * Email * Phone Number * General Practitioner * Medication * YES NO Details Have you had any previous surgeries? * YES NO Details Do you have any ailments? * YES NO Details Have you had an allergic reaction to a previous treatment? * YES NO Details Are you pregnant or breastfeeding? * YES NO Are you under the influence of alcohol or illegal drugs? * YES NO Do you have any allergies or have you experienced any allergic reaction to medicine or products * such as latex, nickel, plaster etc YES NO Do you feel fit and well and able to have the procedure? * YES NO Do you have or are you having any injectables, fillers or chemical peels? * YES NO Do you suffer from epilepsy? * YES NO Do you suffer from haemophilia? * YES NO Do you knowingly have any infectious diseases? * YES NO Do you knowingly have Hepatitis C? * YES NO Do you suffer from shingles? * YES NO Do you suffer from cold sores? * YES NO Do you have any problems with scars healing? * YES NO Do you have high or low blood pressure? * YES NO Do you have hypersensitive skin? * YES NO Do you have any skin abnormalities? * eczema, psoriasis etc? YES NO Do you have or have you suffered from rosacea? * YES NO If you answered yes to any of the above please list If you answered 'YES' to any questions * I understand my condition may affect the treatment including bruising, bleeding, and additional healing time I understand the importance of my accurate and complete medical history and that withholding any medical conditions may be detrimental to my health and the outcome of he procedure. I understand that there are no guarantees as to the success of my treatment. I understand that I must adhere to the aftercare advice. I hereby give my written consent for Anita Wilson to carry out the treatment of my choice. YES Thank you!
