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Consultation Forms
First Name
Last Name
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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…)
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Required
Yes
No
Do you have any autoimmune conditions, cancers, blood disorders, neurological conditions, muscle disorders, facial problems or skin conditions? (Bells palsy, epilepsy etc…)
*
Required
Yes
No
Are you currently under the care of a doctor, clinic, hospital or specialist?
*
Required
Yes
No
Are you taking any medications? If so, which ones.
*
Required
Yes
No
Are you allergic to anything? (Medications, latex, pollen etc…)
*
Required
Yes
No
Are you or could you be pregnant, breastfeeding or undergoing IVF?
*
Required
Yes
No
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