Medical History & Emergency Contact Form

Personal Details

Full Name

Date of Birth

Gender

Address

Postcode

Mobile Phone

Email Address

Occupation

Emergency Contact

Name

Relationship

Phone Number

GP Details

GP Name

Surgery Name

Phone Number

Medical Conditions

Do you have or have you ever had any of the following? (tick all that apply)

Heart disease / Heart conditions

High blood pressure

Low blood pressure

Stroke / TIA

Diabetes (Type 1 or 2)

Thyroid disorder

Epilepsy / Seizures

Asthma / Respiratory conditions

Liver disease

Kidney disease

Blood clotting disorder

Bleeding disorder / Haemophilia

HIV / Hepatitis B or C

Cancer (current or history)

Autoimmune disease

Lupus / Rheumatoid arthritis

Eczema / Psoriasis / Dermatitis

Rosacea

Cold sores (Herpes simplex)

Keloid / Hypertrophic scarring

Mental health conditions

Pacemaker / Metal implants

Other conditions not listed (please specify)

Allergies

No known allergies

If you have allergies, please list them (include medications, foods, latex, plasters, etc.)

Current Medications

I am not taking any medications

Please list ALL medications including prescription, over-the-counter, vitamins, and supplements

Lifestyle & Other Information

Do you smoke?

Yes

Ex-smoker

Alcohol consumption

None

Occasional

Regular

Are you pregnant or breastfeeding?

Yes

Trying to conceive

N/A

Previous Aesthetic Treatments

Have you had aesthetic treatments before? If yes, please list (include Botox, fillers, laser, etc.)

Have you had any complications or adverse reactions to previous treatments?

Declaration

I confirm that the information provided is true and complete to the best of my knowledge. I understand that withholding information may affect my treatment safety. I agree to inform the clinic of any changes to my medical history.

Patient Signature

Date

For Clinic Use:

Reviewed by

Date

Notes