Stardust

Competetive prices performed by a Professional

Stardust

Non Surgical Aesthetic Medical History and Consent 


CONSULTATION DATE:

No

Yes –details please

Do you have any current health or medical problems?

 

 

Have you recently had any medical investigations / tests?

 

 

Are you pregnant / breast feeding / fertility treatment?

 

 

Medication – HRT, anti-biotics, OCP

 

 

Diabetes / Asthma / Liver or Kidney disease?

 

 

Any Allergies  (including non surgical products, adrenaline,

dental anaesthetics Botox , topical medications)

 

 

Anaphylactic shock or other severe allergic reaction?

 

 

Any sever reaction to dental anaesthetics or adrenaline?

 

 

Rapid / slow heart beat or heart problems?

 

 

High or Low Blood Pressure / fainting?

 

 

Aspirin / steroids / anti-coagulants , Warfarin, Heparin

Blood clotting or bleeding disorder? Vitamin E / Gingko supplements?

 

 

 

Prone to bruising?

 

 

Prone to scarring – keloid?

 

 

Neuro-muscular disorder? Bell’s Palsy? Epilepsy? Convulsions? Facial Palsy?

 

 

Hepatitis A, B, C, HIV, auto-immune disorders?

 

 

Cold sores, active skin conditions?(acne / psoriasis / eczema)

History of skin cancer?

 

 

Recent skin peel? Laser treatment? Contact lenses?

 

 

Psychological problems / depression / stress

 

 

Recent surgery / dental surgery?

 

 

Hyper pigmentation / masking during pregnancy?

 

 

Have you been treated with dermal filler before?

 

 

Have you been treated with Botox / Vistabel in the past?

 

 

Are you planning cosmetic surgery?

 

 

 

 

I request topical / local ANAESTHESIA

 N/A

EMLA CREAM 5% (lidocaine & prilocaine) > 10g

 

I request DERMAL FILLER Restylane

 N/A

LIDOCAINE     2%  >  4ml

 

I request BOTOX / Allergen

 

 

 

 

MEDICAL STAFF ONLY

 

Medical History seen by doctor

Practitioner Signature ………………………………………………………..………Date:…………….…

 

Prescription Signatory

 

I have read the medical history for this patient and I am satisfied that there are no contraindications to Botulinum Type A (Initial dose of 20 units to a maximum of 100 units and thereafter every 3 – 6 months if required) or lidocaine topical/ IM anaesthetic and that the treatment is appropriate and safe for this client

I the undersigned have prescribed on behalf of Lorna Amy Patten, RGN, the following to be included in the protocol Clostridium Botulinum Type A, Allergen /Botox reconstituted with Sodium Chloride for IM injection and intradermal injection

 

 

Doctor Signature:…Nurse Prescriber Jayne Molyneax …………..…Authorised for treatment from (date)......................................

 

PLEASE READ

Although Botox/allergen has a product license for the treatment of facial spasms, excessive sweating and muscle relaxation in cerebral palsy, it is used outside this license for cosmetic treatment in this country.  Botox does however have a product license for use in cosmetic treatment of glabellar frown lines in the USA, Canada, Switzerland and France.

 

I understand that results are not guaranteed, but my practitioner will provide treatment to the best of their knowledge.

 

Consent

 

I have been fully informed of the risks and possible consequences involved in the requested treatment. I confirm that this health history is accurate and complete. I have not withheld any known medical information.

I understand that withholding any medical information may be detrimental to my health and safety during this procedure.

I will contact my practitioner if I have any queries about my treatment. I have received after care advice. If there is any change to my health, I accept responsibility to inform the practitioner.

 

Anaesthetic Consent:

I also confirm that the procedure of topical/local anaesthetic has been explained to me and that I have read the information sheet and have had an opportunity to have any questions answered to my satisfaction

 

X      Patient Signature:........................................................................Date:...............................