Search site

Call

020 7637 1600



Latest News:

Patient Questionnaire...

Before you come and visit us, please provide some initial information

Please try to answer the questions below as honestly as possible. The answers will help us provide the best care for you. These notes will never be released to any other person in any form without your express written permission. You can request a copy of all information we hold on you at any time.

Please bear in mind we do charge £100 for the initial consultation for a new patient which is a 30 minute appointment at which time you will have the opportunity to discuss your needs, aims and requirements in great detail and be given all the facts you need to determine what treatment is suitable for you.

The Consultation fee is payable upon booking the appointment, this can be paid by debit or credit card (we do not accept American Express).

If you need to cancel your appointment we will refund the amount charged in full providing we receive the cancellation with at least 24 hours notice.

At the time of your consultation appointment if you go on to book a laser procedure, dermal filler or anti winkle treatments such as Botox ™ we will deduct the amount of the consultation from your first treatment. We find that some clients like to go away and absorb the information they have been given before committing to any treatment plan and some clients would like to go ahead with the treatment straight away. There are certain treatments we can carry out (time permitting) at the time of consultation. However, other treatments need planning, such as laser micro peels, profractional laser treatments and other laser treatments requiring patch testing. Please fell free to call us about this.

First Name*
Surname
DOB (dd/mm/yyyy)*
Age
Address (line 1)
Address (line 2)
Town / City
Country
Postcode
Email
Home Telephone
Work Telephone
Mobile
Referred By
What type of problem are you consulting for? Sun Spots
Wrinkes
Enlarged blood vessels
Flushing of the skin
Large pores
How many years have you noticed this problem?
At what age did your skin problem begin?
Are your present skin problems getting more pronounced?
Have you ever been treated for this problem?
If yes, when?
And by what method?
Are you currently taking medication for your skin problem?
Are you pregnant, nursing, or planning a pregnancy soon?
Do you have a history of keloid scarring?
Do you have a history of? Heart Disease
Herpes sores
Bruising
Skin Injury
Diabetes
Bleeding disorders
Dark spots after pregnancy
Skin cancer, or suspicious moles
Have you had any allergic reactions to anesthesia?
Do you have any skin related allergies?
If yes, please specify
Do you have any allergies to medication?
If yes, please specify
Do you take any medication? Aspirin
Hormones/contraceptives
Thyroid medication
Sedatives
Cortisone
Anti-coagulants (blood thinners)
Appetite depressant(diet pills)
Insulin
Tranquilizers
Other
If you selected other, please enter more details?
Are you taking any herbal preparations? (St. John's Wort)?
If yes, please list
What is your daily consumption of alcohol?
Do you wear contact lenses?
Have you had cold sores or fever blisters?
Mark your skin type (when exposed to the sun for about 1 hour with no protection I. Always burns, never tans
II. Always burns, sometimes tans
III. Sometimes burns, sometimes tans
IV. Always tans
V. Asian, Hispanic, Mediterranean, Middle Eastern
VI. Black
When were you last exposed to the sun (or a tanning booth)?
Do you use chemical sun tanning lotions?
Are you planning a holiday in the sun?
Have you ever had skin resurfacing or rejuvenation or chemical peels?
Have you ever had treatments for pigmented lesions?
Prior treatment, if any?
  * required information

60 Harley Street, London, W1G 7HA | T: 020 7637 1600 F: 020 7612 2509 | Mon-Fri 8.30am-6.00pm Sat 10.30am-3.30pm | info@freedomhealth.co.uk

Home | Private Doctor Services | Sexual Health Services | Aesthetic Services | Meet the Team | Forum | press | Links | Sitemap | Contact Us

Site designed by blowmedia