Intake / Medical History | Aesthetics Forms Portal

Covid / Medical History

To ensure the safety of all parties and to stop the further spread of the Covid-19 virus, please complete the below questions as honestly and accurately as possible prior to your appointment date.

Have you, or anyone in your household, had Covid-19 in the last 14 days? *

Please give details: *

Have you, or anyone in your household, had any of the following symptoms in the last 14 days: Continuous cough, Fever, High temperature, Loss of sense of taste, Loss of sense of smell? *

Please give details: *

Have you received a Covid-19 vaccine? *

Which vaccine did you receive? *

Have you received one or two doses? *

Appointment Guidance

If you have answered yes to some of the above questions, we will be in contact as you may need to reschedule your appointment with us.
Please only attend at your appointment time.
Please ensure you are on time - if you are late this may result in your appointment being cancelled.

Please check statement to show your understanding and agreement. *

I agree not to visit the salon/clinic for any of the services provided if I have the symptoms of Covid-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below I confirm that I understand and agree to all terms and statements in this form.

Client Signature: *

Tap or click on the signature above to sign

Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Address *

Doctor’s Name: *

Medical History

Do you have heart conditions / pacemaker? *

Please specify/give details *

Do you have Diabetes? *

Please specify/give details *

Do you have any skin disorders? *

Please specify/give details *

Do you have Hemophilia or blood disorders? *

Please specify/give details *

Have you been treated or taking medication for Cancer within the last 6 months? *

Please specify/give details *

Do you have Keloid scarring? *

Please specify/give details *

Are you prone to fever blisters or Herpes? *

Please specify/give details *

Do you have hormone imbalances or are you taking hormones? *

Please specify/give details *

Are you currently pregnant or breastfeeding? *

Please specify/give details *

Are you taking oral contraceptives? *

Please specify/give details *

Have you had Hepatitis? *

Please specify/give details *

Do you have metal plates / Pins / Piercings? *

Please specify/give details *

Do you have any tattoos or permanent makeup? *

Please specify/give details *

Do you have respiratory problems? *

Please specify/give details *

Do you have allergies / intolerances? *

Please specify/give details *

Do you have high or low blood pressure? *

Please specify/give details *

Do you have Epilepsy? *

Please specify/give details *

Have you had any surgeries within the last 6 months? *

Please specify/give details *

Medication / previous treatments

Are you taking prescribed medication? *

Please specify/give details *

Are you taking steroids or testosterone? *

Please specify/give details *

Are you using Retin A? *

Please specify/give details *

Are you using Accutane or any other acne medication? *

Please specify/give details *

Are you taking antibiotics? *

Please specify/give details *

Are you taking anticoagulant blood thinners, aspirin, ib prophen, Vitamin E or St John's Wort? *

Please specify/give details *

Have you tanned indoor or outdoor within the last 2 weeks? *