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Home
Latest Offers
Russian Technique/Baby Doll Lips
Anti-Wrinkle & Fillers
Fat Dissolve Injections
IPL Laser Hair Removal
Facial Treatments
Portfolio
Contact

Get In Touch

Digital Consultation

By Tina Allen

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CLIENT INTAKE

Name:

Date of Birth:

Address:

County:

Postcode:

Email Address

Phone Number

Emergency Contact (Phone Number)

Preferred Method of Contract

E-mail Text Phone

Would you like adding to our Mailing List?

Yes No

Please check all the below options that apply to you:

Amyotrophic Lateral Epilepsy Low Blood Pressure Anaphylaxis Eye Disease Lupus Autoimmune Disease Hepatitis Multiple Sclerosis Beef/Dairy Allergy High Blood Pressure HIV/AIDS Neurological Disorders Cardiac Disorders Hypersensitivity Parkinson's Disease Cold Sores Keloid Formation Porphyria Diabetes Labert-Eaton Syndrome Sensitivity to Lidocaine

Any known allergies?

No Yes

If Yes, please list here

Any recent surgeries?

No Yes

If Yes, please list here

Do you suffer from any other conditions that you feel we should be aware of?

No Yes

If Yes, please list here

Please list any medications you take regularly, including vitamins, topicals, etc.

What is your occupation?

What is your sun exposure?

Do you use sun protection (sunscreen , hats, protective clothing) ?

Do you use tanning beds?

Do you smoke?

Do you drink more than 4 caffeinated beverages a day?

What is your alcohol consumption?

Please mention anything else you feel we should be aware of

By submitting this form, I acknowledge that I have read and completed this questionnaire truthfully. I understand t hat with holding information or providing inaccurate details about my medical history, allergies, medications and skin care routines may lead too contradictions or adverse reactions to the treatments I undergo. I agree to inform the technician of any changes in the above information.

By submitting this form, I acknowledge that I have read both our Botox Informed Consent which can be read here and Filler Informed Consent which can be read here documents and acknowledge the details outlined within.

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Russian Technique/Baby Doll Lips
Anti-Wrinkle & Dermal Fillers
Fat Dissolve Injections
Facial Treatments
Portfolio
Contact

Call: 07888 504 958
Email: info@royal-aesthetics.com
Message Tina On WhatsApp
Based In Exeter, Devon
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Tina is a Fully trained, qualified, and insured practitioner providing a range of high-quality aesthetic treatments in Exeter. For more information or to make a booking please get in touch.

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