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About
About
FAQ
Patients’ Journey
FaceLift365 Covid19 Protection
Benefits
Added confidence
Anti-Ageing
Events
Reduce Wrinkles
Skin tightening
Stimulates natural collagen
Tightens the dermis
Features of the Face
Cheeks
Chin
Crows-Feet
Forehead
Full Face Facelift
Jawline
Neck
Treatments
HIFU
RF Resurfacing
Neck & Face Skin Tightening
Promo
Locations
Contact
Menu
About
About
FAQ
Patients’ Journey
FaceLift365 Covid19 Protection
Benefits
Added confidence
Anti-Ageing
Events
Reduce Wrinkles
Skin tightening
Stimulates natural collagen
Tightens the dermis
Features of the Face
Cheeks
Chin
Crows-Feet
Forehead
Full Face Facelift
Jawline
Neck
Treatments
HIFU
RF Resurfacing
Neck & Face Skin Tightening
Promo
Locations
Contact
Customer Contact Form
Please Complete The Form Below
Customer Data form Pre Appointment.
Client Name
*
Date of Birth
*
DD dash MM dash YYYY
Gender
*
Male
Female
Occupation
*
Practitioner Name
*
Post Code
*
Telephone No
*
Your Email
*
Todays Date
*
DD dash MM dash YYYY
Address
*
Health and Lifestyle
Contraindications
Liver/Kidney Disease
*
Yes
No
Heart Conditions inc. Pacemaker
*
yes
No
Silicosis or other Lung Conditions
*
yes
No
Cancer (Radiotherapy/Chemotherapy)
*
Yes
No
Reynaud’s Disease (or other vaso constrictive disorders)
*
Yes
No
Physical Hypotonic
*
Yes
No
Cardiovascular Disease
*
Yes
No
Cerebral Disease
*
Yes
No
Immune System Disease (i.e. AIDS or HIV)
*
Yes
No
Immune System Disease (i.e. AIDS or HIV)
*
Yes
No
Urticarial or other immune disorders
*
Yes
No
Hypoproteinaemia
*
Yes
No
Frostbite Intolerance
*
Yes
No
Hernia or weak stomach muscle walls
*
Yes
No
Severe diabetes
*
Yes
No
Recent invasive surgery (in the last 12 months)
*
Yes
No
Artificial Implants (bone, etc)
*
Yes
No
Metal Plates or Joint Implants
*
Yes
No
Sites of prior cosmetic surgery
*
Yes
No
Pregnant or Breastfeeding
*
Yes
No
Currently under the influence of drugs or alcohol
*
Yes
No
Do you have any of the following?
Hyper or Hypotension
*
Yes
No
Scarring history, fibrosis or seborrhoea
*
Yes
No
Haemophilia or other clotting disorders
*
Yes
No
Epilepsy
*
Yes
No
Diabetes
*
Yes
No
Thyroid Condition
*
Yes
No
Hormonal Imbalances
*
Yes
No
Other immune disorders not listed
*
Yes
No
Received or donated organ transplants
*
Yes
No
Psoriasis or eczema in treatment area
*
Yes
No
Keloid/hypertrophic scar in the region
*
Yes
No
High Cholesterol
*
Yes
No
Thrombosis (past or present)
*
Yes
No
Broken Bones
*
Yes
No
Undiagnosed swelling or inflammation
*
Yes
No
Bruising, cuts or abrasions (treatment area)
*
Yes
No
Fever
*
Yes
No
Menstruation
*
Yes
No
Any other conditions not listed
*
Yes
No
If yes please list:
*
If you have answered yes to any of the above, please give full details:
*
Are you currently taking any medication?
*
Yes
No
Do you exercise?
*
Yes
No
How is your sleep pattern?
*
Good
Average
Poor
How is your diet?
*
Good
Average
Poor
Do you drink alcohol?
*
Yes
No
Do you smoke?
*
Yes
No
If yes, please list all medications
*
No. of Hours Sleep per night:
*
How much water do you drink per day?
*
If yes, how many units per week?
*
If yes, how many cigarettes per day?
*
How often do you exercise per week?
*
Have you ever had cryo body contouring or any fat removal or similar treatments before? If yes, please give details below including the type of treatment and the area.
*
Yes
No
Are you fully committed to making the relevant changes to get the best possible results from your treatment? YES NO
*
Yes
No
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