Clay Clinic

Medical Questionnaire Prior to Aesthetic Treatment

Prior to any treatment all clients must complete a confidential medical questionnaire.

This must be updated annually or if there is any change in your medical history.

First name

Last name

Birthday

Day

Month

Year

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Current health problems?

Yes

No

Past medical history?

Yes

No

Previous medical/ aesthetic surgery (inc. dermal filler, botox, skincare programmes)?

Yes

No

Muscle disorders?

Yes

No

Thrombosis, bleeding or bruising disorders?

Yes

No

Skin conditions, pigmentation, scarring?

Yes

No

Cold sores?

Yes

No

Referred/ under the care of psychologist, psychiatrist or counsellor?

Yes

No

Medications (including topical creams)

Yes

No

Known allergies? Including allergic reactions to latex, dermal fillers, botulinum toxin, anaesthesia (including topical)

Yes

No

Recent sun exposure, use of sun beds/tanning?

Yes

No

Pregnant/breast feeding?

Yes

No

Smoker?

Yes

No

Anything else you may think is relevant?

Yes

No

I am happy for Clay Clinic to use any before and after pictures to promote their services on their website/ social media or by other means

Yes

No

I confirm that the health history is accurate and complete. I understand that withholding information may be detrimental to my health during and after any procedure. If there is a change in my medical history, it's my responsibility to inform Clay Clinic.

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CLAY CLINIC

THE FINE ART OF FACIAL SCULPTING

Medical Questionnaire

Clay Clinic