NEW CLIENT FORM
CONTACT DETAILS
Title: Dr Mr Mrs Ms Miss
First Name:
Surname:
Address:
Date of Birth:
Phone No.:
Email:
Next of kin (emergency contact)
Name:
Contact No.:
LIST PREVIOUS SURGICAL AND NON-SURGICAL COSMETIC
PROCEDURES
OTHER INFORMATION – List surgical and non-surgical
cosmetic procedures you are interested in.
MEDICAL HISTORY
It is important to answer the following questions as accurately as possible. Please ask your physician if you have any questions.
Have you suffered from or undergone:
Allergies or anaphylactic (severe) reactions
Any surgical procedures
Drug dependency/alcohol abuse
Heart Disease
Herpes Simplex
High blood pressure
Neurological disorders
Psychiatric disorders
Respiratory problems
YES
NO
IF YES, PLEASE SPECIFY
Please list Allergies:
MEDICAL HISTORY CONTINUED
It is important to answer the following questions as accurately as possible. Please ask your physician if you have any questions.
Are you:
YES
NO
IF YES, PLEASE SPECIFY
Pregnant or breast feeding:
Using steroids
Using Aspirin, warfarin or other anticoagulants?
(Medications to minimise blood clotting?)
Using any other medication?
(Prescription and / or non-prescription?)
Suffering from other medical conditions?
Have you ever received facial implants or injectables?
Do you smoke?
PLEASE LIST YOUR COSMETIC CONCERNS:
COMMENTS:
WHAT ARE YOUR EXPECTATIONS FROM YOUR TREATMENT