BookWithRuth London, [email protected], London

Medical History and Consent Form

Please note that this medical consent form will be kept confidential and will only be viewed by the Aesthetic Practitioner and clinic team responsible for you whilst undergoing treatment at this Cosmetic Injectables clinic. Your details will not be available to third parties and are stored securely.

If any of the answers on this consent form raise concern for your Aesthetics Practitioner you may be contacted to discuss further or alternatively, these may be discussed at the time of your consultation.

 
Patient Details

Note that bookings cannot be processed unless you provide a valid phone number. Ruth will contact you to confirm treatment areas and to process your deposit payment of £50.

Medical History

Are you attending or receiving treatment from a doctor or specialist?

Are you taking any medication, or herbal remedies (including Antibiotics, Anticoagulants, Muscle Relaxants, St. Johns Wart, Roaccutane)?

Are you taking blood thinning medication (Aspirin, Plavix, Warfarin)?

Are you allergic to local anaesthetic injections, lignocaine, adrenaline or EMLA/ANESTOP/LMX4 cream?

Do you have any known allergies or a history of anaphylaxis (a life-threatening allergic reaction)?

Have you suffered from or had any of the following conditions?

Heart problems including an irregular heartbeat or angina

High or Low Blood Pressure or circulation problems including Raynaud’s Syndrome

Epilepsy/Blackouts

Blood disorders/leukaemia/lymphoma/anaemia/cancer

Autoimmune disease, arthritis or recurrent sore throat.

Diabetes

Contact Dermatitis/Eczema

Keloids (hypertrophic scarring) or recent scar tissue (6 months) This is more common in dark-skinned individuals. See here for a picture

Easy bruising

Cold Sores

Psychiatric Illness/Depression

Do you use sunbeds or sunbathe?

Do you play a woodwind or brass instrument? (Because Botulinum Toxin softens wrinkles through its effect on muscles, it is important that you avoid treatment with Botulinum Toxin around the mouth if you play either of these families of instruments).

Are you pregnant/planning pregnancy/engaged in IVF treatment or are you breast-feeding?

Have you had a consultation or been treated with dermal filler, Botulinum Toxin, laser, chemical peels or microderm abraision before?

Have you had an allergic reaction to any dermal filler or Botulinum Toxin product?

Have you had a consultation or had plastic surgery of the face or neck or are you planning to have surgery?

Optional

Before and after photos are always taken to help assess treatment — these are confidential. However, I give my written consent for my photos to be used to show to future patients, and for marketing purposes.

Treatments

See the available treatments in the photo at the top of this page. Please ask your practitioner if you would like to discuss a treatment which isn’t mentioned above.

I hereby consent to the following:

I have no known allergy to local anaesthetic cream or injections and understand that either or both may be required as part of my treatment.

In having treatments from the treatment provider, I consent to have my aesthetic records maintained for 10 years which is a requirement from insurance companies for all providers of aesthetic procedures.
Any details stored will be done so securely and not used for marketing purposes or any other purpose without prior consent.
This information is maintained under article 9(2) of the GDPR for these reasons:

  • the establishment, exercise or defence of legal claims as necessary.
  • the processing is necessary for public health purposes in the public interest (e.g. protecting against serious cross-border threats to health, or ensuring high standards of quality and safety of health care and of medicinal products or medical devices)

I have been informed about the risks and possible side effects of treatment and accept these risks as my own. I have understood and correctly completed the medical history form.

An undesired cosmetic effect, such as an unexpected appearance after treatment, can usually be avoided by clear communication between patient and Healthcare Professional.

The following section refers only to patients attending a Visage Academy training session as a training patient

Visage Academy Training Course

This medical history section covers all treatments carried out by Visage Aesthetics UK LTD or on a Visage Academy training course. The additional section below, refers to the Visage Academy training course only.

Available treatments and prices are as follows:

All treatments include a consultation and application of local anaesthetic cream.

Anti-wrinkle injections (lasting 3-6 months): Areas include Forehead lines (horizontal lines above eyebrows), Frown lines (vertical lines between eyebrows present or worse with movement), Crow's feet (eye corners) and Mouth corners (drooping mouth corners).

Filler areas include (lasting approx 12 months): Nose-mouth lines, Mouth corners to chin (to replace volume), lips, frown lines (vertical lines between eyebrows present at rest) and other fine lines (anywhere on the face).

See our photo gallery

I hereby consent to the following:

I understand that I am taking part in a Botulinum Toxin and Dermal Fillers training day for doctors, dentists and nurses and that all treatments will be closely supervised by an accredited and insured trainer.

Under these conditions, trainees may practice Botulinum Toxin and Filler treatments on me. I understand that free follow-up is not included as my payment for today covers my treatments today only. That said, I will contact Visage Academy if I have any concerns following treatment so that any issues can be resolved.

I have no known allergy to local anaesthetic cream or injections and understand that either or both may be required as part of my treatment.

I have been informed about the risks and possible side effects of treatment and accept these risks as my own. I have understood and correctly completed the medical history form.

I have downloaded and read the Visage Aesthetics UK Training course ‘aftercare’ document (PDF)

Optional

Before and after photos are always taken to help assess treatment — these are confidential. However, I give my written consent for my photos to be used to show to future patients, and for marketing purposes.

Please sign your name inside the blue box to confirm that you have read and understood all of the above information and advice

Patient Signature

Please sign above
Consent to send Automated Treatment Reminders and to stay in touch

The treatment provider and Flourish would like to maintain a secure record of your: name, email, phone number and last treatments undertaken. This is to send out an automated reminder from the treatment provider to advise when your treatment may start to wear off and to offer a new appointment. We would also like to be able to stay in touch to provide you with information from the treatment provider about promotions or other treatments available. This information will not be shared with any party not named above. You have the right to remove consent for this at any stage by notifying the treatment provider or by opting out at the bottom of any emails from the treatment provider.

By submitting this form you are consenting to store your data privately on our system. Your private data will be held in accordance with data protection regulations.