Eason Aesthetics
All of our clients are required to complete this questionnaire prior to having treatment.
First name *
Surname *
Email address *
House Number/Name *
Street Name *
Postcode *
D.O.B *
You need to be 18+ to have treatment with us
Q1. Have you been vaccinated for coronavirus in the past 2 weeks? *YesNo
Q2. Are you pregnant or currently breast feeding? *YesNo
Q3. Have you had previous medical/aesthetic surgery including Botox or dermal fillers? *YesNo
Q4. Do you suffer from any of the following conditions? *Muscle DisordersThrombosisBleeding Disorders or BruisingSkin ConditionsPigmentation or ScarringCold Sores
Please tick ANY that apply
Q5. Do you have any current health problems? *YesNo
Q6. Are you currently taking any prescribed medication? *YesNo
Q7. Have you ever been referred to or under the care of a Psychologist, Psychiatrist or counsellor? *YesNo
Q8. Do you have any known allergies including reactions to latex, dermal fillers, Botulinum toxins, anaesthesia (including topical)? *YesNo
Q9. Do you smoke? *YesNo
Q10. Have you had recent sun exposure or used a sun bed? *YesNo
Consent for treatment *I have been explained and understood the possible side effects & complications related to my treatment.
By submitting this you confirm that the health history you have given is accurate and complete, you agree to the treatment terms & conditions, you understand that withholding any information may be detrimental to your health during the procedure and if there is any change in your medical history, it is your responsibility to inform your clinician.
