General Consent Form

Covers consultation, advice, patch tests, and applies alongside all treatments.

Please fill out the following form.

First name

Last name

Email*

Phone

Date of birth

Day

Month

Year

Patient Medical History

Currently pregnant or breastfeeding

Known allergies (medications, latex, antiseptics)

Diabetes

Autoimmune disease

Blood disorders / clotting issues

Skin conditions

(eczema, psoriasis, dermatitis)

Heart conditions

Current infection or illness

High blood pressure

Seizures

Asthma

Migraines

Epilepsy

Please list any medical conditions or allergies not mentioned above

Are you currently receiving any medical treatment?

YES

NO

If yes, please provide details:

Previous Aesthetic Treatment

I confirm that the information provided is accurate

I consent to images/videos being taken for medical records.

I consent to anonymized marketing use of images/videos

I consent to treatment following consultation

E. Signature (Full Names)*

07424476653

bottom of page