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Aqualyx
Fat Loss Injections Overview
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Seborrheic Keratosis
Skin Tag Removal
Sun Damage Removal
Viral Verrucae Removal
Wart Removal
Body Sculpting
Body Sculpting Overview
Body Sculpting Injury Rehab
Diastasis Recti Treatment
HI-EMT
Cryolipolysis
Cryolipolysis (Fat Freezing)
Before & After Cryolipolysis
Cellulite
Stubborn Fat Areas
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Ems Incontinence Treatment
EMS Treatment FAQs
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Overactive Bladder Treatment
Stress Incontinence Treatment
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HIFU Overview
Before & After HIFU
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Price Cryolipolysis
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Join Our Team
Home
Services Offered
Aqualyx
Fat Loss Injections Overview
Aqulayx-FAQs
Blemish Removal
Cryopen Skin Imperfections
Actinic Keratoses
Age Spots Removal
Benign Moles Removal
Cherry Angioma Removal
Dermatofibroma Removal
Milia Removal
Seborrheic Keratosis
Skin Tag Removal
Sun Damage Removal
Viral Verrucae Removal
Wart Removal
Body Sculpting
Body Sculpting Overview
Body Sculpting Injury Rehab
Diastasis Recti Treatment
HI-EMT
Cryolipolysis
Cryolipolysis (Fat Freezing)
Before & After Cryolipolysis
Cellulite
Stubborn Fat Areas
Incontinence Treatment
Ems Incontinence Treatment
EMS Treatment FAQs
EMS Treatment For Men
Overactive Bladder Treatment
Stress Incontinence Treatment
HIFU
HIFU Overview
Before & After HIFU
Face
Forehead
Full Face
Femiwand Vaginal Tightening
Vaginal Femiwand
About Us
About
How To Prepare for Your Treatment
Areas
Arms
Back
Body
Brow
CALFS
Chest
Chin
Crow’s Feet
Décolletage
Face
Forehead
Full Face
Hips
Jawline
Neck
Stomach
Thighs
Under Buttocks
Vaginal Femiwand
Prices
Prices
Prices Aqualyx
Prices Blemish Removal
Body Sculpting Prices
Price Cryolipolysis
Prices EMS Incontinence Treatment
Prices Hifu
Prices Femiwand
Contact
Book A Consultation
Contact us
Join Our Team
Customer Treatment Form Bletchley
If you have booked a treatment with us, Thank you! Please now fill in this treatment form!
Contact Us
Client Name
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Occupation
*
Practitioner Name
*
Post Code
*
Telephone No
*
Your Email
*
Todays Date
*
MM slash DD slash YYYY
Address
*
Health and Lifestyle
Contraindications
Liver/Kidney Disease
*
Yes
No
Heart Conditions inc. Pacemaker
*
yes
No
Silicosis or other Lung Conditions
*
yes
No
Cancer (Radiotherapy/Chemotherapy)
*
Yes
No
Reynaud’s Disease (or other vaso constrictive disorders)
*
Yes
No
Physical Hypotonic
*
Yes
No
Cardiovascular Disease
*
Yes
No
Cerebral Disease
*
Yes
No
Immune System Disease (i.e. AIDS or HIV)
*
Yes
No
Immune System Disease (i.e. AIDS or HIV)
*
Yes
No
Urticarial or other immune disorders
*
Yes
No
Hypoproteinaemia
*
Yes
No
Frostbite Intolerance
*
Yes
No
Hernia or weak stomach muscle walls
*
Yes
No
Severe diabetes
*
Yes
No
Recent invasive surgery (in the last 12 months)
*
Yes
No
Artificial Implants (bone, etc)
*
Yes
No
Metal Plates or Joint Implants
*
Yes
No
Sites of prior cosmetic surgery
*
Yes
No
Pregnant or Breastfeeding
*
Yes
No
Currently under the influence of drugs or alcohol
*
Yes
No
Do you have any of the following?
Hyper or Hypotension
*
Yes
No
Scarring history, fibrosis or seborrhoea
*
Yes
No
Haemophilia or other clotting disorders
*
Yes
No
Epilepsy
*
Yes
No
Diabetes
*
Yes
No
Thyroid Condition
*
Yes
No
Hormonal Imbalances
*
Yes
No
Other immune disorders not listed
*
Yes
No
Received or donated organ transplants
*
Yes
No
Psoriasis or eczema in treatment area
*
Yes
No
Keloid/hypertrophic scar in the region
*
Yes
No
High Cholesterol
*
Yes
No
Thrombosis (past or present)
*
Yes
No
Broken Bones
*
Yes
No
Undiagnosed swelling or inflammation
*
Yes
No
Bruising, cuts or abrasions (treatment area)
*
Yes
No
Fever
*
Yes
No
Menstruation
*
Yes
No
Any other conditions not listed
*
Yes
No
If yes please list:
*
If you have answered yes to any of the above, please give full details:
*
Are you currently taking any medication?
*
Yes
No
Do you exercise?
*
Yes
No
How is your sleep pattern?
*
Good
Average
Poor
How is your diet?
*
Good
Average
Poor
Do you drink alcohol?
*
Yes
No
Do you smoke?
*
Yes
No
If yes, please list all medications
*
No. of Hours Sleep per night:
*
How much water do you drink per day?
*
If yes, how many units per week?
*
If yes, how many cigarettes per day?
*
How often do you exercise per week?
*
Have you ever had cryo body contouring or any fat removal or similar treatments before? If yes, please give details below including the type of treatment and the area.
*
Yes
No
Are you fully committed to making the relevant changes to get the best possible results from your treatment? YES NO
*
Yes
No
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