This can be found in your confirmation email

    Personal Information


    Please answer all questions

    Are you...





    a smoker?YesNo

    taking a Contraceptive Pill?YesNo

    taking HRT? YesNo

    Have you ever had…



    Hyaluronidase (Hyluron) for the removal of Dermal Fillers? YesNo

    Jaundice (hepatitis) or other liver disease? YesNo

    Rheumatoid Fever or Chorea (St Vitus Dance)? YesNo

    Asthma, Eczema or other allergic disease? YesNo

    an Anaphylaxis reaction? Do you carry an epi-pen? YesNo

    any heart conditions such as angina, murmur and valve problems? YesNo

    a stroke or blood pressure problems? A valve or joint replacement? YesNo

    an allergic reaction to substances or drugs such as; foods, latex, steroids or antibiotics? YesNo

    a reaction to either Botulinum Toxin or Dermal Fillers? YesNo

    Steroids within the last two years or any recent vaccinations?YesNo

    a valve replacement, joint replacement or implant? YesNo

    an operation or surgical treatment or a general anaesthetic or sedation? YesNo

    a period as an in-patient at a hospital? YesNo

    Do you…

    use any pills, medicines or tablets? YesNo

    use an inhaler or any other form of medication?YesNo

    use any complimentary supplements i.e St John Wort? YesNo

    suffer from fainting attacks? YesNo

    bleed or bruise easily?YesNo

    or any family members have diabetes or epilepsy? YesNo

    suffer from Cold Sores? YesNo

    have any other diseases, illnesses? OR have any other medical condition?YesNo

    If Yes, please note any details