MEDICAL CONSULTATION FORM

The purpose of this consultation form is to assess your suitability for treatment and patient safety. This information will be securely stored for ten years and not shared with any third party.

First name

Last name

Phone

Email

Address

Social Media Name

Birthday

GP Name

GP Address

PREVIOUS COSMETIC TREATMENT:

Have you had any previous cosmetic surgery (minor or major) under local or general anaesthetic?

YES

NO

If yes please give details

MEDICAL QUESTIONNAIRE

Please tick any health conditions which you have ever had previously or are now experiencing.

PLEASE USE THIS SPACE TO ADD MORE INFORMATION