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Consultation Forms
First Name
Last Name
Email
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Birthday
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When did you last have any aesthetic treatment?
I hereby consent to and authorise Aesthetic Coach Online to perform the following procedure:
Confidential medical questionnaire
Do you have any medical problems? (Asthma, diabetes, heart problems 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 allergic to anything? (Medications, latex, pollen etc…)
Yes
No
Are you or could you be pregnant, breastfeeding or undergoing IVF?
Yes
No
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