Complete Prescriber Form

Choose Academy: Choose Academy:ChelmsfordColchesterFrintonLexdenSudbury

What treatment is your Prescriber Form for: What treatment is your Prescriber Form for:BotoxFiller DissolvingVitamin B12 InjectionBiotin InjectionVitamin C InjectionVitamin D InjectionVitamin B Complex InjectionGlutathione InjectionNAD IV DripNAD at Home Kit

Title: Title:MrMrsMissOther

Full Name:

Date of birth: day/month/year

Sex: Sex:MaleFemale

Address:

Postcode:

Home Tel No:

Work Tel No:

Mobile:

Email:

Occupation

Pregnant Pregnant Yes No

Breast Feeding Breast Feeding Yes No

Contraceptive Pill Contraceptive Pill Yes No

Taking HRT Taking HRT Yes No

Do you smoke Do you smoke Yes No

Medical History

Do you suffer from cold sores? Do you suffer from cold sores? Yes No

Have you ever had hyaluronidase (Hyluron) for the removal of Dermal Fillers? Have you ever had hyaluronidase (Hyluron) for the removal of Dermal Fillers? Yes No

Details cold sores?

Details of hyaluronidase use

Jaundice (hepatitis) or other liver disease? Jaundice (hepatitis) or other liver disease? Yes No

Rheumatic fever or Chorea (St Vitus Dance) ? Rheumatic fever or Chorea (St Vitus Dance) ? Yes No

Details of Jaundice or other liver disease

Details of Rheumatic fever or Chorea

Asthma eczema or other allergic reactions? Asthma eczema or other allergic reactions? Yes No

Have you ever had an anaphylaxis reaction? Do you carry an Epi Pen? Have you ever had an anaphylaxis reaction? Do you carry an Epi Pen? Yes No

Details of Asthma eczema or other allergic reactions

Details of anaphylaxis and Epi Pen

Any heart conditions such as angina, murmur and valve problems? Any heart conditions such as angina, murmur and valve problems? Yes No

A stroke or blood pressure problems? A valve or joint replacement? A stroke or blood pressure problems? A valve or joint replacement? Yes No

Details of any heart conditions

Details of a stroke, blood pressure problem, valve or joint replacement

An allergic reaction to substances or drugs such as; foods, latex, steroids, or antibiotics? An allergic reaction to substances or drugs such as; foods, latex, steroids, or antibiotics? Yes No

Have you ever had a reaction to Botulinium Toxin or Dermal Fillers? Have you ever had a reaction to Botulinium Toxin or Dermal Fillers? Yes No

Details of any allergic reactions to substances

Details of reaction to Botulinium or Dermal Fillers

Steroids within the last two years or any recent vaccinations? Steroids within the last two years or any recent vaccinations? Yes No

A valve replacement, joint replacement or implant? A valve replacement, joint replacement or implant? Yes No

Details of steroids within the last two years or recent vaccinations

Details of a valve replacement, joint replacement or implant

An operation or surgical treatment or general anaesthetic or sedation? An operation or surgical treatment or general anaesthetic or sedation? Yes No

A period as an in-patient in a hospital? A period as an in-patient in a hospital? Yes No

Details of any operations, anaesthetics or sedations

Details of in-patient period

Have you any other diseases, illnesses? Or have any other medical condition? Have you any other diseases, illnesses? Or have any other medical condition? Yes No

Details of other diseases, illnesses or other medical conditions

Current Medical Status

Do you take any pills, medicines or tablets? Do you take any pills, medicines or tablets? Yes No

Are you using an inhaler or any other medication? Are you using an inhaler or any other medication? Yes No

Details of pills medicines or tablets

Details of inhalers or other medications

Are you using complimentary supplements ie St John Wort? Are you using complimentary supplements ie St John Wort? Yes No

Do you suffer from fainting attacks? Do you suffer from fainting attacks? Yes No

Details of complimentary supplements

Details of fainting attacks

Do you bleed or bruise easily? Do you bleed or bruise easily? Yes No

Do you or any member of your family have diabetes or epilepsy? Do you or any member of your family have diabetes or epilepsy? Yes No

Details of bleeding or bruising

Details of diabetes or epilepsy

I give my consent for the information provided to be used for the sole purpose of calculating suitability of any requested procedure. I give my consent for the information provided to be used for the sole purpose of calculating suitability of any requested procedure. Yes No

Completed by:

Date: day/month/year

Choose Academy: Choose Academy:ChelmsfordColchesterFrintonLexdenSudbury

What treatment is your form for: What treatment is your form for:BotoxFiller DissolvingVitamin B12 InjectionBiotin InjectionVitamin C InjectionVitamin D InjectionVitamin B Complex InjectionGlutathione InjectionNAD IV DripNAD at Home Kit

Title: Title:MrMrsMissOther

Full Name:

Date of birth: day/month/year

Sex: Sex:MaleFemale

Address:

Postcode:

Home Tel No:

Work Tel No:

Mobile:

Email:

Occupation

Pregnant Pregnant Yes No

Breast Feeding Breast Feeding Yes No

Contraceptive Pill Contraceptive Pill Yes No

Taking HRT Taking HRT Yes No

Do you smoke Do you smoke Yes No

Medical History

Do you suffer from cold sores? Do you suffer from cold sores? Yes No

Details cold sores?

Have you ever had hyaluronidase (Hyluron) for the removal of Dermal Fillers? Have you ever had hyaluronidase (Hyluron) for the removal of Dermal Fillers? Yes No

Details of hyaluronidase use

Jaundice (hepatitis) or other liver disease? Jaundice (hepatitis) or other liver disease? Yes No

Details of Jaundice or other liver disease

Rheumatic fever or Chorea (St Vitus Dance) ? Rheumatic fever or Chorea (St Vitus Dance) ? Yes No

Details of Rheumatic fever or Chorea

Asthma eczema or other allergic reactions? Asthma eczema or other allergic reactions? Yes No

Details of Asthma eczema or other allergic reactions

Have you ever had an anaphylaxis reaction? Do you carry an Epi Pen? Have you ever had an anaphylaxis reaction? Do you carry an Epi Pen? Yes No

Details of anaphylaxis and Epi Pen

Any heart conditions such as angina, murmur and valve problems? Any heart conditions such as angina, murmur and valve problems? Yes No

Details of any heart conditions

A stroke or blood pressure problems? A valve or joint replacement? A stroke or blood pressure problems? A valve or joint replacement? Yes No

Details of a stroke, blood pressure problem, valve or joint replacement

An allergic reaction to substances or drugs such as; foods, latex, steroids, or antibiotics? An allergic reaction to substances or drugs such as; foods, latex, steroids, or antibiotics? Yes No

Details of any allergic reactions to substances

Have you ever had a reaction to Botulinium Toxin or Dermal Fillers? Have you ever had a reaction to Botulinium Toxin or Dermal Fillers? Yes No

Details of reaction to Botulinium or Dermal Fillers

Steroids within the last two years or any recent vaccinations? Steroids within the last two years or any recent vaccinations? Yes No

Details of steroids within the last two years or recent vaccinations

A valve replacement, joint replacement or implant? A valve replacement, joint replacement or implant? Yes No

Details of a valve replacement, joint replacement or implant

An operation or surgical treatment or general anaesthetic or sedation? An operation or surgical treatment or general anaesthetic or sedation? Yes No

Details of any operations, anaesthetics or sedations

A period as an in-patient in a hospital? A period as an in-patient in a hospital? Yes No

Details of in-patient period

Have you any other diseases, illnesses? Or have any other medical condition? Have you any other diseases, illnesses? Or have any other medical condition? Yes No

Details of other diseases, illnesses or other medical conditions

Current Medical Status

Do you take any pills, medicines or tablets? Do you take any pills, medicines or tablets? Yes No

Details of pills medicines or tablets

Are you using an inhaler or any other medication? Are you using an inhaler or any other medication? Yes No

Details of inhalers or other medications

Are you using complimentary supplements ie St John Wort? Are you using complimentary supplements ie St John Wort? Yes No

Details of complimentary supplements

Do you suffer from fainting attacks? Do you suffer from fainting attacks? Yes No

Details of fainting attacks

Do you bleed or bruise easily? Do you bleed or bruise easily? Yes No

Details of bleeding or bruising

Do you or any member of your family have diabetes or epilepsy? Do you or any member of your family have diabetes or epilepsy? Yes No

Details of diabetes or epilepsy

I give my consent for the information provided to be used for the sole purpose of calculating suitability of any requested procedure. I give my consent for the information provided to be used for the sole purpose of calculating suitability of any requested procedure. Yes No

Completed by:

Date: day/month/year