Aboutface Aesthetics
About
Services
Contact Us
Medical History
Profhilo
Aesthetics Pricing

AboutFace Aesthetics Botox Fillers and Profhilo by Dentist Dr Greg Martin

07882 311888

AboutFace Aesthetics, Carwardine Field, Abbeymead, Gloucester, GL4 5TX, United Kingdom

Aboutface Aesthetics
About
Services
Contact Us
Medical History
Profhilo
Aesthetics Pricing
More
- More child

Contact Form and Medical History

Please filll in the following if you wish to make an appointment with Dr Greg at AboutFace Aesthetics and we will be in touch with you shortly.

Title *

First Name *

Surname *

Email *

Address and Post Code *

Date of Birth (format 00.00.0000) *

Phone Number *

Emergency contact name *

Emergency Contact telephone no *

Drs. Name and address

COVID-19 Questions

a. Do you have a new or continuous dry cough?

b. Do you have a high temperature (Over 37.8 C)?

c. Have you been diagnosed with COVID-19?

d. Have you or a member of your household been told to self-isolate ?

e. Have you been identified as shielding or vulnerable?

Are you receiving treatment from a Dr. or hospital? *

Yes

Are you taking or using any prescribed medicines/ointments etc? *

Yes

Do you carry a medical warning card? *

Yes

Are pregnant or possibly pregnant? *

Yes

Do you have any allergies to substances or foods? (eg Penicillin) *

Yes

Do you have Bronchitis, Asthma or other chest condition? *

Yes

Due you suffer from Epilepsy, fainting or blackouts? *

Yes

Do you have Diabetes? *

Yes

Do you have a heart condition, high blood pressure or have you had a stroke? *

Yes

Do you have bone or joint problems? eg Arthritis *

Yes

Do bruise easily or suffer with persistent bleeding? *

Yes

Do you have liver or kidney problems? eg Jaundice or Hepatitis *

Yes

Do you have any other illness or infectious disease? *

Yes

Have you ever needed treatment requiring you to be in hospital? *

Yes

Have you ever had heart surgery or a pacemaker fitted? *

Yes

Do you smoke tobacco? *

Yes

Do you drink alcohol? *

Yes - Under15 units per week on average

Yes - 15 units or more per week on average

If you have answered yes to any of the above answers please add more details here.

some-randome-random

Aboutface Aesthetics
About
Services
Contact Us
Medical History
Profhilo
Aesthetics Pricing
More
- More child

07882 311888

Greg@AboutFace-Aesthetics.co.uk

AboutFace Aesthetics, Carwardine Field, Abbeymead, Gloucester, GL4 5TX, United Kingdom