Client Form 01

Consultation & Medical History

Complete this before treatment planning so the consultation starts with the information that matters.

Client Details

Full name Date of birth Email Phone

What Would You Like To Discuss? Main concern or area you would like to discuss What would you prefer to keep untouched? What would a good outcome look like to you?

Medical History Medical conditions, diagnoses or ongoing health concerns Current medication Allergies or previous allergic reactions

Are you currently pregnant or breastfeeding?

Yes No

Recent procedures, dental work or medical treatment that may be relevant

Previous Aesthetic Treatment

Have you had aesthetic treatment before?

Yes No

If yes, what treatment, when, where and by whom? Any previous reaction, complication, dissatisfaction or corrective treatment?

Appearance & Expectations Is there anything about your appearance that is currently causing significant distress or affecting day-to-day life? Anything else you believe may affect treatment suitability or planning?

Terms & Privacy I confirm that the information I have provided is accurate to the best of my knowledge. I have read the Terms & Conditions and Privacy Policy.

This website version does not transmit medical information yet. The form will be connected to a secure submission system before launch.