Prescriber Form Lexden Salon

Confidential Prescriber Form Brown and White – Lexden Salon

This form will form part of your confidential clinical records. This form will be updated at every consultation appointment

Please simply complete the online Prescriber Form below or if you would prefer, you can download and print it here to bring it with you

Pregnant

Breast Feeding

Contraceptive Pill

Taking HRT

Do you smoke

Do you suffer from cold sores?

Have you ever had hyaluronidase (Hyluron) for the removal of Dermal Fillers?

Jaundice (hepatitis) or other liver disease?

Rheumatic fever or Chorea (St Vitus Dance) ?

Asthma eczema or other allergic reactions?

Have you ever had an anaphylaxis reaction? Do you carry an Epi Pen?

Any heart conditions such as angina, murmur and valve problems?

A stroke or blood pressure problems? A valve or joint replacement?

An allergic reaction to substances or drugs such as; foods, latex, steroids, or antibiotics?

Have you ever had a reaction to Botulinium Toxin or Dermal Fillers?

Steroids within the last two years or any recent vaccinations?

A valve replacement, joint replacement or implant?

An operation or surgical treatment or general anaesthetic or sedation?

A period as an in-patient in a hospital?

Have you any other diseases, illnesses? Or have any other medical condition?

Do you take any pills, medicines or tablets?

Are you using an inhaler or any other medication?

Are you using complimentary supplements ie St John Wort?

Do you suffer from fainting attacks?

Do you bleed or bruise easily?

Do you or any member of your family have diabetes or epilepsy?

11 + 5 =

Pregnant

Breast Feeding

Contraceptive Pill

Taking HRT

Do you smoke

Do you suffer from cold sores?

Have you ever had hyaluronidase (Hyluron) for the removal of Dermal Fillers?

Jaundice (hepatitis) or other liver disease?

Rheumatic fever or Chorea (St Vitus Dance) ?

Asthma eczema or other allergic reactions?

Have you ever had an anaphylaxis reaction? Do you carry an Epi Pen?

Any heart conditions such as angina, murmur and valve problems?

A stroke or blood pressure problems? A valve or joint replacement?

An allergic reaction to substances or drugs such as; foods, latex, steroids, or antibiotics?

Have you ever had a reaction to Botulinium Toxin or Dermal Fillers?

Steroids within the last two years or any recent vaccinations?

A valve replacement, joint replacement or implant?

An operation or surgical treatment or general anaesthetic or sedation?

A period as an in-patient in a hospital?

Have you any other diseases, illnesses? Or have any other medical condition?

Do you take any pills, medicines or tablets?

Are you using an inhaler or any other medication?

Are you using complimentary supplements ie St John Wort?

Do you suffer from fainting attacks?

Do you bleed or bruise easily?

Do you or any member of your family have diabetes or epilepsy?

1 + 2 =

What you can expect

Vouchers & Promotions

Comfy Waiting Area

Gender Friendly

Free Client Coffee

We are a five star salon

We have been awarded 5 Stars and recognised as a top of the range salon with highly qualified staff and personalised services by The Good Salon Guide!

Every Good Salon Guide recognised salon is assessed using criteria that has been developed since 1993 following ongoing consultation with the general public and hairdressing industry. Check out our listing at www.thegoodsalonguide.com

We are a five star salon

We have been awarded 5 Stars and recognised as a top of the range salon with highly qualified staff and personalised services by The Good Salon Guide!

Every Good Salon Guide recognised salon is assessed using criteria that has been developed since 1993 following ongoing consultation with the general public and hairdressing industry. Check out our listing at www.thegoodsalongguide.com

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