• MEDICAL QUESTIONNAIRE PRIOR TO TREATMENT

    MMT aesthetics LTD
  •  -
  • DateTime
  • Treatment choice/s:*

  • Health Questionnaire

  • Have you had a Coronavirus Antibody test? If yes, was it:*
  • Current Health Problems?*
  • Past Medical History?*
  • Previous Medical/Aesthetic Surgery (including dermal filler, Botox, skincare programmes)*
  • Muscle Disorders?*
  • Thrombosis, bleeding disorders, bruising?*
  • Skin conditions, pigmentation, scarring?*
  • Cold Sores?*
  • Referred/Under the care of psychologist, Psychiatrist or counsellor?*
  • Medications (including topical creams)*
  • Known allergies? Including allergic reactions to latex, dermal fillers, Botulinum toxins, anaesthesia (including topical) or any other products previously injected for aesthetic purposes*
  • Recent sun exposure, use of sun beds/tanning?*
  • Pregnant/Breast feeding?*
  • Smoker?*
  • Anything else you may think is relevant?*

  • 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*
  • I have read and agree to MMT aesthetics's policies (see website page - 'Policies')*
  • 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.*

  • 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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