Medical Questionnaire

Please fill out the following form to help us understand your medical condition.

First Name

Contact Number

Last Name

Email Address

Contraindications

For health and safety reasons, it is imperative that you answer correctly. Please tick the conditions that are applicable to you

Open facial wounds or lesions

Electrical implants such as pacemakers

Metal stents/implants in the face or neck (dental implants ok)

Within two weeks after having Botox

Pregnant or breast-feeding

Permanent dermal implants

Anti-thrombosis therapy

Active systematic or skin disease which may hinder regeneration

Hemorrhagic disorders or dysfunctions

Disease or trauma, inflammation

Skin disease/infection

Feeling numb or no response to cold and/or heat

Skin irregularities

Suffer from migraines

Do you have any current general illnesses? *

Yes

No

If you answered yes, please elaborate

I declare that the info I’ve provided is accurate & complete

Initials

Today's Date

Thanks for submitting!

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