Palis Medical Aesthetics

01 Patient Details

First Name

Last Name

Date of Birth

Phone Number

Email Address

Address

GP Name

GP Surgery

02 Treatment Today

Select all treatments being performed today

Anti-Wrinkle

Lip Enhancement

Cheek & Mid-Face

Jawline & Chin

Brow Lift

Microneedling

Consultation Only

Appointment Date

Appointment Location

03 Medical History

Please answer all questions honestly. This information is kept strictly confidential and is used solely to ensure your safety.

Are you pregnant, breastfeeding, or trying to conceive?

Do you have any known allergies (including to lidocaine, botulinum toxin, hyaluronic acid)?

Are you currently taking any medications, supplements, or blood thinners?

Do you have any autoimmune conditions (e.g. lupus, rheumatoid arthritis)?

Do you have a history of cold sores or herpes simplex?

Do you have any active skin conditions, infections, or open wounds in the treatment area?

Have you had any previous aesthetic treatments (botox, fillers, threads, etc.)?

Have you ever had an adverse reaction to an aesthetic treatment?

Do you have a tendency to form keloid or hypertrophic scars?

Any other medical conditions, recent surgery, or health concerns we should be aware of?

04 Risks & Information — Please Read & Confirm

Please read each statement carefully and tick to confirm you have understood.

05 Photography Consent

Before and after photographs are taken for clinical records. Please indicate your consent for additional use:

Clinical records only (required)

Anonymous use for before/after portfolio

Use on Palis social media (face shown)

I do not consent to any photography

06 Patient Declaration & Signature

I confirm that I have read and understood this consent form. I have had the opportunity to ask questions and all questions have been answered to my satisfaction. I consent to the treatment(s) indicated above being performed by Dr Dhillon of Palis Medical Aesthetics.

Full Name (print)

Date

Patient Signature

07 Practitioner Section — Dr Dhillon

Product Name

Batch Number

Expiry Date

Units / Volume Used

Injection Sites

Dilution

Clinical Notes

Practitioner Name

Date

Practitioner Signature