Medical History Form Title * Mr Mrs Miss Ms Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of birth * MM DD YYYY Phone * (###) ### #### Email * Occupation Do you have any known health conditions? * Are you currently taking any medications? * Are you taking steroids, aspirin, warfarin or anticoagulants (medication to minimise blood clotting)? * Have you had any previous facial aesthetics? If yes, please specify treatments and dates? * Do you have any skin conditions/diseases? * Do you have any allergies or a history of anaphylactic reactions? * Do you have a known sensitivity to Lidocaine (numbing agent commonly used by dentists or doctors)? * Yes No Do you have a hypersensitivity to Hyaluronic acid or any other injectable dermoaesthetic product? * Yes No Are you pregnant or breastfeeding? * Yes No Any other relevant medical information? * What are your areas of concern? What are you hoping to achieve? * Why have you decided to do it now? * Please sign or initial * Thank you!