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Treatments
Anti-wrinkle injections
Polynucleotides – AMI Eyes
Lip treatments
Cheek Fillers
Dermal fillers
Liquid rhinoplasty
Under eyes
PDO Threads
Fat Dissolving
Lemon bottle
Aqualyx
Skin boosters
Filler dissolving
Microneedling
B12 injection
Prices
Models
TEXT
CALL
BOOK
Consent
Form
Name
Address
Post Code
Phone No
Email address
Date of Birth
Sex
Select your Sex
Male
Female
Next of Kin name
Relationship
Next of kin Phone No
Name and address of GP
Occupation
Do you smoke
Do you Smoke
Yes
No
If so, how many?
Do you drink alcohol?
Do you drink alcohol
Yes
No
If so, how many units a week?
What is your hight (CM)
What is your weight (KG)
Are you currently breastfeeding?
Are you currently breastfeeding?
Yes
No
Date of last menstrual period
Do you suffer from pigment disorders?
Do you suffer from pigment disorders?
Yes
No
Do you suffer from increased scar formation?
Do you suffer from increased scar formation?
Yes
No
Do you suffer from increased light sensitivity?
Do you suffer from increased light sensitivity?
Yes
No
Do you suffer from herpes infections? ((Shingles, chickenpox, cold sores, genital herpes)
Do you suffer from herpes infections?
Yes
No
Do you suffer from keloid scarring?
Do you suffer from keloid scarring?
Yes
No
Do you suffer from acne, psoriasis or any other active skin condition or infection in the area (s) you wish to have treated?
Do you suffer from acne, psoriasis or any other active skin condition or infection in the area (s) you wish to have treated?
Yes
No
Do you suffer from Amyotrophic lateral sclerosis (ALS)
Do you suffer from Amyotrophic lateral sclerosis (ALS)
Yes
No
Do you suffer from Myasthenia gravis, Eaton-Lambert syndrone or multiplr sclerosis?
Do you suffer from Myasthenia gravis, Eaton-Lambert syndrone or multiplr sclerosis?
Yes
No
Do you have an impaired ability to swallow or have dysphagia?
Do you have an impaired ability to swallow or have dysphagia?
Yes
No
Do you have, Angina or a cardiac infarction?
Do you have, Angina or a cardiac infarction?
Yes
No
Do you have low or high blood pressure?
Do you have low or high blood pressure?
Yes
No
Do you have any emotional or neurological disorders, E.G seizures (epilepsy), paralysis, depression, M.E.(Myalgic Encephomyelitis)?
Do you have any emotional or neurological disorders, E.G seizures (epilepsy), paralysis, depression, M.E.(Myalgic Encephomyelitis)?
Yes
No
Do you suffer from migraines?
Do you suffer from migraines?
Yes
No
Do you have Bell's palsy or have you had a stroke?
Do you have Bell's palsy or have you had a stroke?
Yes
No
Do you have Glaucoma?
Do you have Glaucoma?
Yes
No
Do you have Asthma?
Do you have Asthma?
Yes
No
Do you have Diabetes?
Do you have Diabetes?
Yes
No
Do you thyroid problems?
Do you thyroid problems?
Yes
No
Have you got HIV, hepatitis, rheumatoid arthritis, or any other form of autoimmune disease?
Have you got HIV, hepatitis, rheumatoid arthritis, or any other form of autoimmune disease?
Yes
No
Do you suffer from nosebleeds, bruising (after a light touch) or coagulation disorders or bleeding disorders?
Do you suffer from nosebleeds, bruising (after a light touch) or coagulation disorders or bleeding disorders?
Yes
No
Do you or anyone in your family suffer from a hereditary disease?
Do you or anyone in your family suffer from a hereditary disease?
Yes
No
Do you have any allergies or hypersensitivities? E.G.hayfever, asthma, hypersensitivity (E.G.to collagen, containing products, lidocaine, painkillers, anaesthetics, foods, medications, plasters or latex?
Do you have any allergies or hypersensitivities? E.G.hayfever, asthma, hypersensitivity (E.G.to collagen, containing products, lidocaine, painkillers, anaesthetics, foods, medications, plasters or latex?
Yes
No
Have you ever been in hospital with a severe allergic reaction?
Have you ever been in hospital with a severe allergic reaction?
Yes
No
Are you currently undergoing any desensitisation treatment? (if you have an allergy card, please present it)
Are you currently undergoing any desensitisation treatment? (if you have an allergy card, please present it)
Yes
No
Have you recently taken any medications are are you currently taking medication? Painkillers, coagulation, inhibitors, antibiotics, steroids, muscle relaxants is (E.G.aspirin, warfarin, ibuprofen, or herbal preparations, vitamins, and supplements).
Have you recently taken any medications are are you currently taking medication? Painkillers, coagulation, inhibitors, antibiotics, steroids, muscle relaxants is (E.G.aspirin, warfarin, ibuprofen, or herbal preparations, vitamins, and supplements).
Yes
No
Have you taken Roaccatane ir Isotretionoin (for acne) in the past 12 months?
Have you taken Roaccatane ir Isotretionoin (for acne) in the past 12 months?
Yes
No
Have you had any major surgery in the last six weeks?
Have you had any major surgery in the last six weeks?
Yes
No
Are you planning on or are you currently undergoing dental treatment?
Are you planning on or are you currently undergoing dental treatment?
Yes
No
Have you previously undergone operations in your facial area (E.G.laser, skin, peel, facelift, IPL skin, resurfacing, plastic surgery, injury, et cetera?
Have you previously undergone operations in your facial area (E.G.laser, skin, peel, facelift, IPL skin, resurfacing, plastic surgery, injury, et cetera?
Yes
No
Do you have a phobia about blood or needles?
Do you have a phobia about blood or needles?
Yes
No
Are you prone to bruising?
Are you prone to bruising?
Yes
No
Have you recently been on a sunbed?
Have you recently been on a sunbed?
Yes
No
Have you received local anaesthetic injections at your dental practice?
Have you received local anaesthetic injections at your dental practice?
Yes
No
Have you had any problems with dental local anaesthetics?
Have you had any problems with dental local anaesthetics?
Yes
No
How how long ago did you receive wrinkle reduction injections?
Have you had any problems with dental local anaesthetics?
Have you received dermal filler injections?
Yes
No
What was the name of the dermal filler used?
Do you have any permanent implants in your face?
Do you have any permanent implants in your face?
Yes
No
Did you experience any side-effects or allergies?
Did you experience any side-effects or allergies?
Yes
No
Which aspects of your face are you concerned about and what are your expectations about the outcome of the treatment?
Do you have any worries or concerns about treatments or anything else you wish to tell us?
Acceptance 1
The use of and indications for the products I will be treated with have been explained to me by my practitioner and I have had the opportunity to have all questions answered to my satisfaction. I have been specifically informed of the following: after the treatment some common injection related reactions might occur. These reactions include redness, swelling, pain, itching, bruising and tenderness at the treatment site. These reactions are generally described as mild to moderate and typically resolve spontaneously a few days after treatment. If there has been multiple injections in one particular area of the face over a short period of time, significant bruising may occur. Additionally, haematomas or bruising under the skin, can happen if the patient moves when injecting dermal filler and could potentially last up to 3 weeks. These reactions are normal and are to be expected.
Acceptance 2
Other types of reaction are rare, but approximately one in every 10,000 patients treated with a dermal filler has experienced localised allergic reactions after one or more injection treatments. These have usually consisted of swelling and firmness at the treatment site, sometimes affecting the surrounding tissues. Redness, tenderness and rarely acne- like formations have also been reported. These reactions have either started a few days after injections or after a delay of several weeks. They have been described as mild to moderate and self limiting, with an average duration of two weeks. In rare instances such reactions or lump formations like granulomas have persisted for a number of months.
Acceptance 3
On very rare occasions (less than one in 15,000) prolonged firmness, abscess formation or greyish discolouration at the implant site has occurred. These reactions can develop weeks to months following the injections and may persist for several months but normally resolve with time. Even more rarely, the formation of a scar and sloughing (shredding) of tissue at the treatment site has been noted, which could result in a shallow scar. In a study published in 2013, 6 visual disturbance cases were reported; 3 were following glabellar frown line treatment with dermal filler.
Acceptance 4
My practitioner has also informed me that depending on the product used, area treated, skin type and the injection technique, the effect of treatment can last 6-12 months. (Lip enhancement will last approx. 6 months). In some cases duration may be shorter or longer. Follow-up treatment will help to maintain the desired correction. My practitioner has advised me of the amount of product required and the cost of the treatment which I agree to pay in full at the time of treatment.
Acceptance 5
For muscle relaxation injections with Botulinum toxin Type A: I have been advised by my practitioner of the expected outcomes and risks associated with this treatment based on the current product. Summary of Product Characteristics (SmPC). In particular, we have discussed realistic outcomes regarding the onset of action and the duration of effect, together with the potential side effects including those relating to the site of injection and the generalised common and uncommon side effect including headaches, muscle activity disorders (raised eyebrows), feeling of heaviness in the upper part of the face, accumulation of fluid in the eyelids (eyelid oedema), dropping eyelids (eyelid ptosis), inflammation of the eyelid, eye pain, blurred vision fainting, noises in the ears (tinnitus), nausea, dizziness, muscle twitching, muscle cramps, localised muscle weakness in the face (dropping eyebrow), dry mouth, flu symptoms, influenza, bronchitis, inflammation of the nose and throat, infection and in rare cases, excessive muscle weakness and difficulties in swallowing. In the event of an adverse event my practitioner has advised me to see medical care immediately.
Acceptance 6
I have been given and have understood the aftercare advice that my practitioner has provided me with and understand that complications could occur if this advice is not strictly adhered to.
Acceptance 7
The information that I have given is to the best of my knowledge and correct
Acceptance 8
I have not knowingly withheld any medical or surgical information
Acceptance 9
I agree to inform my practitioner of any changes to my medication or health in the future.
Acceptance 10
I have read the above information fully and understand the possible complications that could occur. I have discussed these with my practitioner and agree to treatment
I consent to the use of a topical anaesthetic cream.
I consent to the use of a topical anaesthetic cream.
Yes
No
I consent to the use of lidocaine (injected anaesthetic) products during treatment
I consent to the use of lidocaine (injected anaesthetic) products during treatment
Yes
No
I consent to the use of my anonymised before and after photos for educational and promotional purposes.
I consent to the use of my anonymised before and after photos for educational
and promotional purposes.
Yes
No
Where did you hear about us?
Where did you hear about us?
Referral
Internet search
Social media
Leaflet
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