CONSULTATION | Rebecca Gladman

First name

Last name

Email

Phone

DATE OF BIRTH

Day

Month

Year

Address

Social Media Name

GP Name

GP Address

Have you had any previous cosmetic surgery (minor or major) under local or general anaesthetic?

YES

NO

Have you had any of the following? Botox, Dermal Fillers (temporary or permanent)?

YES

NO

If yes please give details:

Any discrepancies must be taken up with the practitioner within 1 month of treatment. All deposits and booking fees are non-refundable unless agreed to with the practitioner.

MEDICAL CONSULTATION FORM