CONSULTATION FORM | GC BEAUTY &AESTHETIC

Are you currently in good health?

Do you take regular exercise?

Have you previously received BOTOX/ DERMAL FILLER injections?

Are you, or could you be pregnant, going through IVF or breastfeeding?

Do you carry a warning card, an EpiPen, or have you ever had an anaphylaxis reaction?

Do you use ANY medication, ointments or inhalers herbal/natural supplements or topical creams on a regular basis?

Any recent vaccinations (including Covid), cortisone injections or steroids?

Have you had any cold sore breakouts (oral herpes) in the past year?

Do you have ANY allergies

Do you have Asthma, Eczema or other allergic disease?

Are you currently under a specialist, hospital or doctor’s care?

Do you have a history of Keloid Scarring?

Any circulative problems or varicose veins?

Do you bruise or bleed easily?

Do you have Angina, murmur, valve or other heart conditions?

A stroke or any other blood pressure problems?

Do you have an autoimmune disease? (e.g. Crohn’s disease)

Do you have any blood-borne diseases?

Do you have AIDS/HIV?

Have you ever had cancer?

Do you have Jaundice, Hepatitis, Liver or Kidney disease?

Any endocrine disorders? (diabetes, thyroid)?

Do you have ANY current or chronic medical illness, or neurological conditions such as: epilepsy, Bell’s Palsy, MS, Chorea, Myasthenia Gravis, Amyotrophic Lateral Sclerosis or any other Neuromuscular disorders?

Have you had eyelid or facial surgery, Replacements, implants, operations, X-rays recently?

Do you suffer with Acne, or have you taken medication for Acne in the past 6 months?

Any other diseases, illnesses or treatments not listed?

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