Botox – what happens during my visit

We pride ourselves on our consultation to offer the best experience for our patients whether it be for botox, dermal fillers, or skin in Stevenage, Hertfordshire.

One of the first things we do, will be for you to fill in a medical and skin questionnaire – see below. This allows us to treat you safely and make sure we address any concerns you may have.

Botox in hertfordshire is a very safe procedure, however there are certain medical conditions or allergies or medication you maybe on, that we need to be aware of, so we can advise you correctly.

MEDICAL HISTORY FORM

NAME:

DATE OF BIRTH:

ADDRESS:

 

MOBILE NUMBER:

E-MAIL ADDRESS:

DOCTOR/SURGERY NAME, ADDRESS AND CONTACT NUMBER:

 

ARE YOU CURRENTLY RECEIVING ANY MEDICAL TREATMENT? Y/N

 

ARE YOU PREGNANT OR BREAST FEEDING? Y/N

DO YOU SUFFER FROM COLD SORES? Y/N

 

PLEASE LIST ANY ALLERGIES:

 

PLEASE LIST ANY CURRENT MEDICATIONS YOU ARE TAKING:

 

DO YOU HAVE ANY HEALTH CONCERNS THAT MAY POSSIBLY EFFECT TREATMENT? Y/N

 

ARE YOU CONCERNED WITH ANY FINE LINES OR WRINKLES? Y/N

ARE YOU CONCERNED WITH YOUR SKIN COMPLEXION? Y/N

ARE YOU CONCERNED WITH A LOSS OF VOLUME ON YOUR FACE? Y/N

 

How did you hear about us?_____________________________________________________

Please sign and date to agree that the above information is correct.

 

Patient Signature: Date:

Doctor Signature: Date:

 

For more information regarding botox hertfordshire, please call us on 01438 300111.