CONSENT AND MEDICAL FORM Medical Form 2024 Client DetailsFirst NameLast NameEmailPhone/MobileAre you over the age of 18? Yes NoDate of BirthAddressAddress Line 1Address Line 2TownCountyPost CodePreviousNextMedical QuestionsI understand that I will not take any of the following 2 days prior to treatment, ALCOHOL, ASPRIN, ANTI-INFLAMMATORIES (i.e Ibuprofen) and ANTABUSE (Treatment for alcohol use disorder) I also understand I will inform my doctor before coming off any prescription drugs, please tick to confirm I understandAre you currently pregnant or breastfeeding? Yes NoHave you ever had a dental injection to numb your mouth? Yes NoDo you have a blood disorder or bleed easily from minor cuts? Yes NoDo you have difficulty breathing or rapid heart beat with a dental injection? Yes NoTick below to confirm that you have none of the above contraindications I confirmHave you ever had a reaction to any of the following? Antiseptics Food Glycerine Metals PigmentsIf you have had a reaction to any of the above please give details belowPlease list current medications and any taken in the last 6 monthsPlease list any drug/medical allergies I should be aware of?What treatment are you having?- Select -EyebrowsEyelinerLipsAreolaDermal FillerAnti-Wrinkle InjectionsDo you suffer from cold sores/blisters? (lip treatments only) Yes NoHave you had chemotherapy or radiation therapy in the last 12 months (if yes you must obtain a doctors consent to proceed)? Yes NoHave you ever had a reaction to local anaesthetics? Yes NoHave you had any reaction to a bee or wasp sting or anaphylaxis? Yes NoBelow are a list of options, if you tick any unfortunately I cannot treat you. Everything listed below is a contraindication (a medical reason I cannot treat you); Accutane Acne Treatment (within 6 months) AHA or Retin A (within 4 weeks of treatment) Botox (2 weeks either side of treatment) Chapped Lips (lip treatment only) Cuts or Abrasions (in treatment area) Contagious Disease Dermal Fillers (under 6 weeks since last treatment) Eye Infection Present Epilepsy Seizure (in the last 2 years) Haemangioma / Strawberry Marks (on treatment area) Impetigo Keloid Scar (in treatment site) Lash Extensions (if having eyeliner treatment) Lazer or IPL (recent in treatment area) Psoriasis (in treatment area) Scleroderma Shingles in treatment area (within 12 months) Sunburn Spray Tan or Sunbed (within 4 weeks) Tuberculosis Present Undiagnosed Condition (in treatment area) Vitiligo (white patches in the skin) Neuromuscular Disorders (myasthenia gravis, Eaton Lambert Syndrome or amyotrophic lateral sclerosis)PreviousNextAntiwrinkle Injections DisclaimerAzzalure® (Botulinum Toxin Type A) uses the toxin produced by the bacteria responsible for botulism in food poisoning. However, the amount of toxin used is minimal and generally well tolerated in clinical trials. The toxin temporarily weakens the muscles responsible for developing facial expression lines caused by muscle activity. Static facial lines, e.g. those due to sun damage, will not usually respond to treatment with botulinum toxin, as they are not caused by muscle activity. Azzalure® (Botulinum Toxin Type A) is licensed for the temporary improvement of moderate to severe vertical lines between the eyebrows (glabellar lines) and is injected into the skin to reduce these lines. You are having these injections because the severity of your lines has had an important psychological impact on you. Treatment is not recommended if you are pregnant or breastfeeding. After treatment with Azzalure® you should start to see an improvement within 2 to 3 days; the full effect can take up to 30 days. The benefits of treatment usually last between 4 and 6 months but can vary depending on your individual response. The most common side effects of Azzalure® are headache and injection reactions e/g/ redness, swelling, irritation, rash, itching, numbness, pain, discomfort, stinging, bruising, and bleeding. Normally these reactions are mild to moderate, reversible and occur in the first week after treatment. There is also a small possibility of slight dropping of the eyelid or visual problems. Very rarely, botulinum toxin may result in muscle weakness away from the side of injection. Other side effects are listed in the Patient information leaflet (please ask if you have not been given this). If any symptoms last for more than one week or you are concerned about any symptoms, you should report them to your practitioner as soon as possible. Seek urgent medical help if you have difficulties breathing, swallowing, speaking or if your face swells up. Azzalure® may cause temporary blurred vision or muscle weakness. If affected, you should not drive or use machinery. Azzalure® contains a very small amount of albumin, which comes from human blood. It is very unlikely that this could pass on an infection, but it cannot be entirely ruled out. I understand that sometimes antiwrinkle injections can be a process and multiple treatments may be required over a period of time to achieve the desired outcome. I understand results are not always guaranteed. I herby agree that I have received and reviewed this informed consent and medical questionnaire to the best of my knowledge. I confirm once again that I am, over the age of 18 and not pregnant or breastfeeding. I understand that the outcome is variable due to the health of skin and individual results vary on a number of factors such as age, skin, muscle tone and lifestyle. I am aware that poor health conditions can result in poor results. I understand that antiwrinkle injections will diffuse over time due to environmental and lifestyle factors. I agree and accept the permanency of the procedure as well as the possible complications and consequences of said procedure. I acknowledge that no guarantees have been given concerning the results of the procedure. I hereby declare that the above information is true and I authorise Natalie Rogers to perform upon myself antiwrinkle injections. If any unforeseen condition arises in the course of the procedure(s) I further request and authorise her to use her full judgement and do whatever she deems advisable and necessary in the circumstances. Injection of Azzalure is not recommended in patients with a history of dysphagia (swallowing difficulties) and aspiration (accidental inhalation of food and other solids into the lungs). By completing this form I agree, when necessary, to give consent for my information to be shared with the prescriber and medical supplier.Derma Fillers DisclaimerRISKS AND COMPLICATIONS Understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalisation, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising, and discolouration; 2) Post treatment infection associated with any transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localised necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs. I understand that sometimes dermal fillers can be a process and multiple treatments may be required over a period of time to achieve the desired outcome. I understand results are not always guaranteed. I herby agree that I have received and reviewed this informed consent and medical questionnaire to the best of my knowledge. I confirm once again that I am, over the age of 18 and not pregnant or breastfeeding. I understand that the outcome is variable due to the health of skin and individual results vary on a number of factors such as age, skin, muscle tone and lifestyle. I am aware that poor health conditions can result in poor results. I understand that dermal fillers will diffuse over time due to environmental and lifestyle factors. I agree and accept the permanency of the procedure as well as the possible complications and consequences of said procedure. I acknowledge that no guarantees have been given concerning the results of the procedure. I hereby declare that the above information is true and I authorise Natalie Rogers to perform upon myself dermal fillers. If any unforeseen condition arises in the course of the procedure(s) I further request and authorise her to use her full judgement and do whatever she deems advisable and necessary in the circumstances.Permanent Makeup DisclaimerI understand that PMU / semi permanent makeup is a process with healing variables, therefore healed colour cannot be guaranteed. I understand that permanent makeup is a multi treatment process with colour being implanted slowly and carefully over a period of time in a layering process. I understand that additional work cannot be undertaken for 4 weeks, in order for the skin to fully heal. I understand that all colours will fade and alter with time. To keep a fresh appearance, a re-touch procedure will be will be required every 12-18 months. Fade is dependent on age, skin type, medication and colour chosen and sun exposure. I understand that if I wish to donate blood I must check the current guidelines as to when I can donate again after a cosmetic tattoo. I understand that if I have an MRI or CAT scan I must tell the radiologist that I have had a cosmetic tattoo. I may experience a slight tingling in the treated area. I herby agree that I have received and reviewed this informed consent and medical questionnaire to the best of my knowledge. I confirm once again that I am, over the age of 18 and not pregnant or breastfeeding. I consent to the use of topical anaesthetic when considered necessary. I understand that the colour outcome may be slightly modified due to undertone and health of skin and individual results vary on a number of factors such as age, skin type and lifestyle. I am aware that poor health conditions can result in poor results. I understand that permanent makeup will fade/diffuse over time due to environmental and lifestyle factors. I agree and accept the permanency of the procedure as well as the possible complications and consequences of said procedure. I acknowledge that no guarantees have been given concerning the results of the procedure. I hereby declare that the above information is true and I authorise Natalie Rogers to perform upon myself a permanent cosmetic enhancement. If any unforeseen condition arises in the course of the procedure(s) I further request and authorise her to use her full judgement and do whatever she deems advisable and necessary in the circumstances.Please sign here to confirm you have read and understood the above questions Sign Here I herby agree that I have received and reviewed this informed consent and medical questionnaire to the best of my knowledge. I understand Previous Submit Form This error message is only visible to WordPress admins Error: No connected account. Please go to the Instagram Feed settings page to connect an account.