Client Form 04

Corrective Care Assessment

For concerns following previous filler treatment, including treatment performed elsewhere.

Client Details

Full name Date of birth Email Phone

Previous Treatment What treatment was performed?

Date of treatment Practitioner / clinic

Product used, if known Areas treated

Current Concern Describe what has happened and what concerns you now When did the concern or symptoms first appear? Any pain, heat, colour change, swelling, visual symptoms, breathing difficulty or other symptoms? What action or treatment has already been taken?

Medical Information Current medical conditions, medication or allergies

If you believe you are experiencing a medical emergency, do not wait for a website response. Seek urgent medical care through the appropriate emergency services.

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.