Aesthetics Patient Form

01 Patient Details

First Name *

Surname *

Date of Birth *

H&C Number *

Health & Care number. This can be obtained from your GP or dentist.

N/A — ROI / Non-UK resident

Address *

Town / City

Postcode *

Mobile Number *

Email Address *

GP / Practice Name

Next of Kin Name

Next of Kin Contact Number

Relationship to Patient

02 Medical History

Please answer Yes or No for each. If Yes, please give details.

Are you pregnant or breastfeeding?

Yes No N/A

Please give details

Do you have diabetes?

Yes No

Please give details

Do you have epilepsy?

Yes No

Please give details

Do you have a heart condition or pacemaker?

Yes No

Please give details

Do you have an autoimmune disease?

Yes No

Please give details

Do you have or have you had cancer?

Yes No

Please give details

Are you on blood thinners / anticoagulants?

Yes No

Please give details

Do you have a history of keloid scarring?

Yes No

Please give details

Do you have an active skin infection?

Yes No

Please give details

Do you have eczema, psoriasis, or rosacea?

Yes No

Please give details

Have you had chemotherapy or radiotherapy?

Yes No

Please give details

Any other significant medical conditions?

Yes No

Please give details

Current Medications (name and dose)

Known Allergies (medications, latex, adhesives, skincare, other)

03 Aesthetics & Skin History

Have you had Botox / toxin injections before?

Yes No

Please give details

Have you had dermal fillers before?

Yes No

Please give details

Have you had chemical peels before?

Yes No

Please give details

Have you had laser or IPL treatments before?

Yes No

Please give details

Have you taken Roaccutane / isotretinoin?

Yes No

Please give details (including when you stopped)

Are you currently using retinoids / vitamin A products?

Yes No

Please give details

Do you suffer from cold sores / herpes simplex?

Yes No

Please give details

Previous allergic reaction to skincare products?

Yes No

Please give details

Sun or sunbed exposure in the last 2 weeks?

Yes No

Last treatment & approximate date

Current skincare / products in use

04 Marketing & Communication Preferences

I consent to being contacted by phone regarding my care / treatment

Yes No

I consent to being contacted by text or email regarding my care / treatment

Yes No

I consent to marketing or promotional offers being sent via text or email

Yes No

05 Photography Consent

I consent to photographs being taken for my records

Yes No

I consent to my photographs being used anonymously for marketing purposes

Yes No

06 Pre-Treatment Advice

Please read the following advice relevant to your treatment before signing.

Injectables (Botox / Fillers)

Avoid aspirin / ibuprofen 48 hrs prior if medically safe
No alcohol for 24 hrs before and after
Arrive with clean skin — no make-up
Avoid strenuous exercise for 24 hrs after
Do not fly within 24 hrs of filler treatment

Laser / IPL / Energy Treatments

No sun, sunbed, or fake tan for at least 2 weeks before
Avoid retinoids and acids for 1 week before
Shave treatment area 24 hrs before (laser hair removal)
Patch test must be completed at least 48 hrs prior
No perfume / deodorant on treatment area on the day

Chemical Peels

Avoid retinoids, AHAs/BHAs for 5–7 days before
Use SPF50 daily for at least 2 weeks before
No waxing or threading on the area for 1 week prior
Arrive with clean, make-up free skin
Do not treat sunburned or actively broken-out skin

Facials & Skin Treatments

Arrive with clean skin — no heavy make-up or SPF
Avoid retinoids 48 hrs prior if you have sensitive skin
Tell your therapist of any recent reactions or new products
Hydrate well before your appointment
No professional treatment on the same area within 2 weeks

I confirm I have read and understood the pre-treatment advice above *

Yes — I have read and understood the above

07 Consent & Declaration

I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that withholding relevant medical information may affect the safety of my treatment. I consent to Belfast Skin Clinic holding my personal and medical data for treatment purposes in accordance with GDPR (UK) and the Data Protection Act 2018. Data will not be shared with third parties without my consent. I consent to the proposed treatment(s) and understand I may withdraw consent at any time before the treatment begins.

Signature *

Sign here with your finger or mouse

Date

Thank you