top of page
Log In
HOME
ABOUT
MEET JAMIE
MODEL CLUB
POLICIES
CLINIC POLICIES
PRIVACY POLICY
MEMBERSHIP POLICY
PACKAGE POLICY
Search Results
DERMAL FILLERS
ANTI WRINKLE
SKIN/HAIR TREATMENT
BLEMISH
BODY CONTOURING
LASER HAIR REMOVAL
IV/ VITAMIN
MEMBERSHIP & PACKAGES
LOYALTY CLUB
OFFERS
CONTACT US
FIND US
THE LEADING AESTHETIC
CLINIC IN AYLESBURY
Consultation Forms
First Name
Last Name
Phone
Email
Date of Birth
Street Address
Street Address Line 2
City
Postal / Zip code
Country
FOR OFFICE USE ONLY
Confidential medical questionnaire
Do you have any medical problems? (Asthma, diabetes, heart problems etc…)
*
YES
NO
Are you allergic to anything? (Medications, latex, pollen etc…)
*
YES
NO
Do you have any autoimmune conditions, cancers, blood disorders, neurological conditions, muscle disorders, facial problems or skin conditions? (Bells palsy, epilepsy etc…)
*
YES
NO
Are you currently under the care of a doctor, clinic, hospital or specialist?
*
YES
NO
Are you taking any medications? If so, which ones.
*
YES
NO
Are you or could you be pregnant, breastfeeding or undergoing IVF?
*
YES
NO
When did you last have any aesthetic treatment?
I hereby consent to and authorise Enhance Beauty to perform the following procedure:
Next
bottom of page
_edited.png)