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THE LEADING AESTHETIC
CLINIC IN AYLESBURY

Consultation Forms

FOR OFFICE USE ONLY

Confidential medical questionnaire
Do you have any medical problems? (Asthma, diabetes, heart problems etc…)
Are you allergic to anything? (Medications, latex, pollen etc…)
Do you have any autoimmune conditions, cancers, blood disorders, neurological conditions, muscle disorders, facial problems or skin conditions? (Bells palsy, epilepsy etc…)
Are you currently under the care of a doctor, clinic, hospital or specialist?
Are you taking any medications? If so, which ones.
Are you or could you be pregnant, breastfeeding or undergoing IVF?
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