MEDICAL QUESTIONNAIRE PRIOR TO TREATMENT

MEDICAL QUESTIONNAIRE PRIOR TO TREATMENT

MMT aesthetics LTD
Name *

First Name Last Name
Birth Date *

Day Month Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
DateTime
Treatment choice/s: *

Consultation Botox/Hyperhidrosis Dermal fillers B12 injection Mesotherapy Fat dissolving Profhilo Sunekos PRP (platelet-rich-plasma)

CONSENT AGREEMENT

PLEASE SELECT YOUR TREATMENT AND READ CAREFULLY
Dermal Fillers

Profhilo

PRP (platelet-rich-plasma)

Mesotherapy

Botox

Fat Dissolving Injections

B12 Injections

Sunekos

(no consent forms necessary for Consultations)
I confirm I have read the necessary consent form/s *

Yes No N/A (consultations only)
I confirm that the health history is accurate and complete. I understand that withholding any information may be detrimental to my health during the procedure. If there is any change in my medical history, it is my responsibility to inform the practitioner. *

Yes No
Signature *

Clear
Please note: for treatments using Botulinum Toxin a copy of this completed form will be sent to our Doctor to be reviewed before your prescription for Botulinum Toxin can be sent to your aesthetics practitioner. You may be contacted once your consent form has been reviewed to answer any relevant questions. You will be informed as soon as possible if the treatment can not go ahead.
www.MMTaesthetics.co.uk contact@MMTaesthetics.co.uk
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Health Questionnaire