Online Botulinum Toxin A Form

First name *

Surname *

Address *

Postcode *

Date of Birth *

Contact Number

Email

Have you or anyone in your household had COVID-19? *

Yes
No

Do you have or have you had a high temperature in the last 7 days? *

Yes
No

Please select the treatment you require an appointment for *

If you treatment is not in the list, please call the clinic

Have you previously been treated with Dermal Fillers/PDO threads ? *

Yes
No

Dermal / Threads Information

Are you pregnant, breast feeding or trying to conceive (LMP) ? *

Yes
No

Any allergies/ had allergic reaction ? *

Yes
No

Any localized infection/cold sores? *

Yes
No

Infections and/or Sores information

Please enter details in regards to localized infections and/or sores

Do you suffer from any other medical conditions? *

Yes
No

Medical Condition Information

Please list all medical conditions where possible

Suffer from CNS disease, neurological disorder, including migraine or epilepsy? *

Yes
No

Head symptoms Information

Please list symptoms here

Take any other medication (incl. over the counter or herbal medicines)? *

Yes
No

Medication Information

Have you taken Aspirin/NSAIDs/Clopidogrel/Warfarin /Antibiotics recently? *

Yes
No

Do you consent to photos being taken before and after treatment? *

Yes
No

Botulinum Toxin A

THE FOLLOWING POTENTIAL ADVERSE EVENTS HAVE BEEN FULLY EXPLAINED AND UNDERSTOOD BY ME:
Mild swelling or stinging at the injection sites, itching, headaches, bruising, rash, temporary loss of nearby muscles or localized numbness.
I will advise my Practitioner should I experience any of the aforementioned adverse events. 
I confirm that to the best of my knowledge that the information that I have supplied is correct and that there is no other medical information I need to disclose.
I consent to receiving Botulinum Toxin-A. I understand that more than one treatment session may be required to obtain maximum effects and no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement not perfection.
I give permission that any prescription issued by Kama Clinical Services on behalf of the client will be kept by Kama Clinical Services in anticipation of treatment. All Client information is kept in compliance with the Data Protection Act. (2018)

Alert!