Consultation Form – HM Beauty Salon in London

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Form

Medical Health Form

Name

Contact No

Address

Date of Birth

Name of Docter

Surgery

Please answer all the following questions:

Have you taken any of the following in the last 2 day Aspirin, Ibuprofen, Coumadin, Alcohol ?

YES NO

Have you received chemotherapy of radiation treatment in the last year?

YES NO

List any medications you have been taking in the last 6 months

Allergies have you ever had an allergic reaction to any of the following

YES - Lanolin Metals Latex Rubber Hair dyes Vaseline Lidocaine Medication Drugs Paints Crayons Foods Glycerine NO - Lanolin Metals Latex Rubber Hair dyes Vaseline Lidocaine Medication Drugs Paints Crayons Foods Glycerine

Anaesthetics or Adrenaline (which ones)

Other allergies (list)

Have you or have you ever had any of the following? Tick all of the following that apply

Abnormal Heart Condition Mitral Valve Prolapse Cold Sores (herpes simplex Heart Murmur Artificial Heart Volves Pacemaker Anaemia Haemophilia Prolonged Bleeding Diabetes High Blood Pressure Epilepsy Low Blood Pressure Fainting Spells or Dizziness Circulatory Problems Thyroid Disturbances Liver Disease Glaucoma Kidney Disease Stomach Ulcers umours, Growths or cysts Cancer HIV uberculosis Prosthetic Hip or loint Stroke Cataracts Palpitations Blurred Vision Hepatitis Dry Eyes Pregnant or Nursing in the 12 months Eye Infection present Watery Eyes Alopecia Recent Hair Loss Contact Lenses Chapped Lips Eyelid Surgery Date of last yeasleyebrow tint Trichotillomania Bruise or Bleed Easily Gore-Tex Implants/Silicone Injections Other Tattoos Fat Transfer Injections Botox injections Collagen Injections Hypertrophic Scars Chemical or laser peel within 6 months Keloid Scars Sensitivity to Cosmetics Use of Sun bed Scar Easily or healing problems Retin A within 6 months Cortisone within 6 months AHA preparations within last 2 weeks Acutance within 6 monthsconfirm that the above

I confirme information is correct

YES NO

Name

Signature

Date

Technician Name

Signature

Date