0207 622 8685

TOA CLINIC

Multi Award Winning Clinic
LONDON 2019 - 2020 2021 - 2022

Profhilo Consent Form

Please fill out the following form
in order to participate in our activity.

First Name

Last Name

Date of Birth

Phone

Street Address

Photographs taken shall be part of the medical record and used for documentation of response to treatment. With explicit permission these photographs may also be used for educational purposes or for client information.

As part of the marketing activity (digital and/or print) we would like to use anonymously before & after photos of your treatment for use to promote this treatment.

As far as I am aware and my doctor/nurse, there is no reason that I can not have botox.

I understand that the treatment takes a full 2 weeks to take effect anlsts for 3 months, in rare occasions more.

I give consent to the practitioner to carry out the procedure.

Are you currently in good health?

YES

cardiac pacemakers, implanted defibrillators, implanted neurostimulators

YES

drug pumps

YES

Do you carry a warning card, an EpiPen, or have you ever had an anaphylaxis reaction?

YES

malignant tumor

YES

Fever

YES

sensitivity or allergy to latex

YES

haemorrhagic conditions

YES

anticoagulation therapy

YES

heart disorders

YES

epilepsy

YES

Are you currently under a specialist, hospital or doctor’s care

YES

areas of the skin which lack normal sensation

YES

Do you use ANY medication, herbal/natural supplements or topical creams on a regular basis

YES

Do you have ANY allergies to medications, food, latex, or other substances

YES

Have you had any cold sore breakouts (oral herpes) in the past year

YES

Do you have a history of Keloid Scarring

YES

Any blood-borne diseases

YES

A stroke or any other blood pressure problems

YES

Any neurological conditions such as epilepsy, Bell’s Palsy, MS, Chorea or Myasthenia Gravis

YES

Allergic to latex, antibiotics, foods, drugs/substances

YES

Any recent vaccinations, cortisone injections or steroids

YES

Replacements, implants, operations, X-rays recently

YES

Do you suffer with Acne, or have you taken medication for Acne in the past 6 months

YES

Do you have ANY current or chronic medical illness, including: Myasthenia Gravis, Amyotrophic Lateral Sclerosis or any other Neuromuscular disorders

YES

Do you have an autoimmune disease

YES

Jaundice, Hepatitis, Liver or Kidney disease

YES

Have you ever had eyelid or facial surgery

YES

Asthma, Eczema or other allergic disease

YES

AIDS/HIV

YES

Deep skin peeling

YES

Have you previously received BOTOX/ DERMAL FILLER injections

YES

When did you have this? Which areas, any adverse reactions?

Are you, or could you be pregnant

YES

Are you going through IVF

YES

Are you breastfeeding

YES

Taking medicines, pills, tablets, ointments or inhalers

YES

Use therapies or supplements such as St. John’s Wort?

YES

If YES please tell us, also inform us of any other medical conditions you may have or surgeries.

Do you bruise or bleed easily

YES

Any circulative problems or varicose veins

YES

Any auto-immune disease, including lupus

YES

Any endocrine disorders? (diabetes, thyroid)

YES

Do you follow a healthy diet?

YES

The first of its kind, Profhilo® is a revolutionary 'beneath the skin' hyaluronic acid moisturising treatment, made with the patented NAHYCO® technology. This results in a unique hyaluronic acid injectable gel, which has a prolonged stimulating activity on the dermal cells. When injected into skin, Profhilo® stimulates the skin cell receptors to counteract skin laxity and improve and restore firmness of the skin. One of the highest concentrations of hyaluronic acid on the market, Profhilo® not only boosts and hydrates the skin, but also remodels ageing and sagging tissue. The most common areas of treatment include the face and neck and can also be used for the décolletage, hands, arms, knees and abdomen area where it would effectively treat skin laxity. The treatment is suitable for men and women as well as offering skin benefits for patients of all ages.

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Multi Award Winning Clinic LONDON 2019 - 2020 2021 - 2022

Profhilo Consent Form

Multi Award Winning Clinic
LONDON 2019 - 2020 2021 - 2022