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"Beauty Is Being Comfortable & Confident In Your Own Skin"

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Skin Boosters & PN
Consultation Form

First Name

Age

Last Name

Sex

Date of Birth

Email address

Phone

Emergency contact

Do you have a history of excessive scarring or keloid formation?

Yes

Are you pregnant or breastfeeding?

Yes

Have you ever been diagnosed with any of the following? Please check all that apply:

Autoimmune Disorders

Skin Infections/Active Skin Inflammation

Bleeding Disorders

Rheumatoid Arthritis

Taking Blood Thinners

Bleeding Disorder

History of Herpes or Cold Sores

Lupus

Diabetes

Other

If 'Other', please detail:

Please list any medications or supplements you are currently taking:

Have you ever had skin boosters or polynucleotidies treatment before? If yes, please provide details.

Yes

If yes, please describe

Have you ever had any adverse reactions to skin boosters or polynucleotides or any other cosmetic treatments? If yes, please specify.

Yes

If yes, please describe

Do you have any allergies, especially to lidocaine, salmon or any other local anesthetics? If yes, please provide details:

Yes

If yes, please describe

Have you had any recent dental or facial surgeries? If 'Yes', please provide details:

Yes

If yes, please describe

Are you currently undergoing any other cosmetic treatments or planning to have any in the near future? If 'Yes', please provide details:

Yes

If yes, please describe

Is there anything else in your medical history that you believe is important for us to know? If "Yes", please provide details:

Yes

If yes, please describe

What specific concerns would you like to address with this treatment?

Have you noticed any asymmetry or unevenness in your facial features?

Yes

If yes, please describe

Are you satisfied with the volume and shape of your lips and cheeks?

Yes

If yes, please describe

Are there any specific facial features or areas that you would like to enhance?

Yes

If yes, please describe

By signing below I have read and understand this agreement and all information detailed above. I understand the procedure and accept the risks. I do not hold the nurse, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure.

Thanks for submitting!

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Skin Boosters & PN Consultation Form

Skin Boosters & PN
Consultation Form