top of page
ROGUE_Banner
Date of birth
Day
Month
Year
Do you have any known current health conditions or medical history?
Yes
No
Do you confirm that your personal details on this medical form are correct?
Yes
No
Do you have any past medical history?
Yes (please give details below)
No
Are you currently under investigation or awaiting a specific diagnosis?
Yes (please give details below)
No
Do you take any regular medications?
Yes (please give details below)
No
Do you have any allergies?
Yes (please give details below)
No
Have you had any aesthetics / cosmetic treatments
Yes (please give details below)
No
Have you had any issues with previous aesthetics / cosmetic treatments in the past?
Yes (please give details below)
No
Do you have any concerns about the treatment you are about to receive or any further health related information you need to declare?
Yes (please give details below)
No
Are you pregnant or breastfeeding?
Yes
No
Are you currently taking any medication?
Yes (please give details below)
No
Do you consent for your before / after images to be used for the purpose of training and / or promotion?
Yes
No

Please sign your name here to give consent to receive treatment and confirm you understand all of the above questions and any risks associated with your treatment.

Date and time
Day
Month
Year
Time
HoursMinutes
bottom of page