Medical History Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Procedure *

Botox

Dermal Filler

Are you currently taking any medication? *

Yes

No

Are you currently pregnant, breast feeding or on fertility treatment? *

Yes

No

Do you suffer from allergies? *

Yes

No

Have you ever suffered from anaphylaxis as a result of botox or dermal fillers? *

Yes

No

Are you currently receiving any medical treatment? *

Yes

No

Have you ever had a non-surgical treatment before? *

Yes

No

Have you ever had a reaction after receiving treatment? *

Yes

No

Do you suffer from any illnesses? e.g. angina, epilepsy, diabetes, auto immune system, hepatitis, HIV positive? *

Yes

No

Do you suffer from any cutaneous infection or inflammatory problems? e.g. herpes/ acne. *

Yes

No

Are you currently taking blood thinners, steroids or anticoagulants e.g (warfarin, aspirin,)? *

Yes

No

Have you recently undergone surgery? *

Yes

No

Do you suffer from high or low blood pressure? *

Yes

No

Are you prone to bruising? *

Yes

No

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country