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Medical Summary Form

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Title

Name *

First

Last

Date of Birth *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Telephone number *

The best number for us to reach you on

Email Address *

Biologic Sex *

Male
Female

Are you: Likely to be pregnant, Undergoing fertility treamtent, or Breastfeeding? *

Yes
No

Treatment with Botulinum Toxin is not recommended if you are (likely to be) pregnant or breastfeeding

What are your main aesthetic concerns?

Have you had aesthetic injectables before? *

Yes, Dermal Fillers
Yes, Botulinum Toxin
Yes, Both
No

Did you have any unwanted side effects? *

Yes
No

Please Specify *

Your Medical Conditions

Are you currently under the care of a doctor, clinic or hospital? *

Yes
No

Please Specify *

Do you carry a Medical Warning Card? *

Yes
No

What does the warning card state? *

Give details of any medical warning cards

Are you allergic to anything that you know of? *

Yes
No

What are you allergic to? *

Give details of any known allergies

Do you suffer from Myasthenia Gravis, Amyotropic Lateral Sclerosis (ALS) or other Neuro-Muscular Disorders? *

Yes
No

Treatment with Botulinum Toxin is not recommended if you suffer from any Neuro-Muscular disorders

Do you get regular cold sores? *

Yes
No

You may still get facial injectables in the lip region, but it may be advisable to get a covering course of anti-viral medication; please get in touch with us as soon as possible

Do you get Keloid scarring when you are injured? *

Yes
No

Michael Rodger, Sander van der Molen; CC BY 3.0 , via Wikimedia Commons

If you have a tendency for Keloid scarring, it is unadvisable to get injectables in your face

Have you had facial, or eyelid surgery? *

Yes
No

Which areas was the surgery and when was it performed? *

What Is Your Drug History?

Do you take Steroids? *

Yes
No

Are you taking Blood Thinners at the moment? *

Yes
No

Which blood thinner/s do you take? *

Aspirin
Clopidogrel
Dipyridamole
Prasugrel
Tricagrelor
Warfarin
Acenocoumarol
Phenindione
Apixaban
Edoxaban
Rivaroxaban
Dabigatran
Dalteparin
Enoxaparin
Tinzaparin

Are you taking Macrolide antibiotics at the moment? *

Yes
No

Macrolides include: Azithromycin Clarithromycin Dirithromycin Erythromycin Spiramycin & Troleandomycin

Treatment with Botulinum Toxin is not recommended if you are currently taking Macrolide antibiotics

Are you suffering from Active Dermatosis, Acne, or taking Roaccutane at the moment? *

Yes
No

Treatment with Dermal Fillers is not recommended if you are currently suffering from active dermatosis or are taking Roaccutane

Do you take any other medication? *

Yes
No

Do you take any 'alternative medication'? *

Yes
No

Including illicit, herbal remedies or 'off-label' medication

Please give details of any medication or alternative medicines you take *

Alcohol Consumption

Selected Value: 0

Units Per Week

Tobacco Usage

Selected Value: 0

Times Per Day

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