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Complete Prescriber Form

This form will form part of your confidential clinical records. This form will be updated at every consultation appointment.

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Please simply complete the online Prescriber Form below or if you would prefer, you can download and print it to bring it with you.

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Please note, LBL Aesthetics and Laser do not keep your medical information beyond uploading it to our designated prescriber.
 

Title
Sex
Pregnant
Yes
No
Breast Feeding
Yes
No
Contraceptive Pill
Yes
No
Taking HRT
Yes
No
Do you smoke
Yes
No

Medical History

Do you suffer from cold sores?
Yes
No
Have you ever had hyaluronidase (Hyluron) for the removal of Dermal Fillers?
Yes
No
Jaundice (hepatitis) or other liver disease?
Yes
No
Rheumatic fever or Chorea (St Vitus Dance) ?
Yes
No
Asthma eczema or other allergic reactions?
Yes
No
Have you ever had an anaphylaxis reaction? Do you carry an Epi Pen?
Yes
No
Asthma eczema or other allergic reactions?
Yes
No
Have you ever had an anaphylaxis reaction? Do you carry an Epi Pen?
Yes
No
Any heart conditions such as angina, murmur and valve problems?
Yes
No
A stroke or blood pressure problems? A valve or joint replacement?
Yes
No
Have you ever had a reaction to Botulinium Toxin or Dermal Fillers?
Yes
No
An allergic reaction to substances or drugs such as; foods, latex, steroids, or antibiotics?
Yes
No
A valve replacement, joint replacement or implant?
Yes
No
Steroids within the last two years or any recent vaccinations?
Yes
No
A period as an in-patient in a hospital?
Yes
No
An operation or surgical treatment or general anaesthetic or sedation?
Yes
No
Have you any other diseases, illnesses? Or have any other medical condition?
Yes
No

Current Medical Status

Do you take any pills, medicines or tablets?
Yes
No
Are you using an inhaler or any other medication?
Yes
No
Do you suffer from fainting attacks?
Yes
No
Are you using complimentary supplements ie St John Wort?
Yes
No
Do you bleed or bruise easily?
Yes
No
Do you or any member of your family have diabetes or epilepsy?
Yes
No
I give my consent for the information provided to be used for the sole purpose of calculating suitability of any requested procedure.
Yes
No
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