Birthday*

Are you currently in good health?*

Do you follow a healthy diet?*

Do you take regular exercise?*

Do you have any heart concerns?*

Do you have high blood pressure?*

Do you have a history of cancer?*

Do you have any blood disorders?*

Do you suffer from any mental health condition? *

Do you have Epilepsy?*

Do you have low serum levels of potassium?*

Do you suffer from Diabetes type 1?*

Has your GP given you a B12 deficiency blood test recently?*

Do you have any other medical conditions?*

Are you pregnant / breastfeeding/ lactating or trying to get pregnant?*

Do you have a neuromuscular disease (e.g. MS, ALS, motor neuropathy myasthenia gravis, or Lambert-Eaton syndrome)?*

Do you have an autoimmune disease?*

Do you have any skin conditions?*

Are you taking antibiotics or other prescription medications?*

Concurrent use of aminoglycoside?*

Do you use anticoagulants? E.g. Warfarin/Aspirin etc...*

Do you have any known allergies or have ever had anaphylaxis?*

Do you know the brand and product of Anti-Wrinkle injections you are having?*

Is there any other Medical and/or Social History that we should know? *

Have you had this or a similar treatment before? If so, did you experience any problems?*

Do you have any concerns?*

Do you understand the information you have been provided?*

Do you feel sufficient information has been provided to you, to enable you to consent?*

Has your consent been freely given?*

I will retain this information throughout the course of my treatment and refer to it as required.*

Date Signed*