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Order Reference*
This can be found in your confirmation email
First Name* Last Name*
Date of Birth* Gender
Height Weight
Email Address* Contact Number*
Occupation*
Home Address*
Emergency Contact Name* Contact Number*
Please answer all questions
Are you...
Yes
No
Pregnant?YesNo
Breastfeeding?YesNo
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
I agree and acknowledge all of the above.
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