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Eden Forms
Anti-wrinkle Injection Treatment Informed Consent Form
Chemical Peels Dermafrac And Dermapen Treatments Personal History
Chemical Peels, Dermafrac And Dermapen Treatment Aftercare Sheet
Client Info for Hair Treatments
Dermal Filler Treatment Informed Consent Form
Hyaluronidase Administration Consent Form
Informed Consent Form For Facial Depigmentation Treatment Cosmelan
Informed Consent Anti-acne Treatment Acne Solution
Prescription Form For Injection Of Botox, Dysport & Dermal Fillers
Personal History For Hair And Skin Treatments
Tattoo Removal Personal History
Tattoo Removal Consent Form
Thread Lift Informed Consent Form
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Buy Online
Eden Forms
Anti-wrinkle Injection Treatment Informed Consent Form
Chemical Peels Dermafrac And Dermapen Treatments Personal History
Chemical Peels, Dermafrac And Dermapen Treatment Aftercare Sheet
Client Info for Hair Treatments
Dermal Filler Treatment Informed Consent Form
Hyaluronidase Administration Consent Form
Informed Consent Form For Facial Depigmentation Treatment Cosmelan
Informed Consent Anti-acne Treatment Acne Solution
Prescription Form For Injection Of Botox, Dysport & Dermal Fillers
Personal History For Hair And Skin Treatments
Tattoo Removal Personal History
Tattoo Removal Consent Form
Thread Lift Informed Consent Form
Prescription Form For Injection Of Botox, Dysport & Dermal Fillers
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Prescription Form For Injection Of Botox, Dysport & Dermal Fillers
Title
Dr
Mr
Mrs
Ms
Miss
First Name
(Required)
Last Name
(Required)
Sex
Male
Female
Date of Birth
DD slash MM slash YYYY
Address
Suburb
Post Code
Mobile Number
(Required)
Email
(Required)
State
(Required)
Choose state
New South Wales
Australian Capital Territory
NSW Clinics
(Required)
Choose clinic
Hornsby
Eastgardens
Liverpool
Bankstown
Sans Souci
Penrith
Lidcombe
Macarthur
Hurstville
ACT Clinics
(Required)
Choose clinic
Canberra
Are You A Previous Patient Of Eden Laser Clinics?
Yes
No
Would you like to receive marketing materials for promos or sales?
Yes
No
If Yes, Which Method?
Email
SMS
How did you hear about us
Google
Social Media
Flyers
Referral
Walk by
Advertisement
Voucher
Event
Referral from:
Specify Where:
Date Of Consultation
MM slash DD slash YYYY
Requesting Nurse If Applicable
MEDICATION
Dilution:
Botox: 2.5 ml / 4 ml normal saline
Administration:
By Injecting Nurse
NO more than 100 u Botox in a 3 month period (exception hyperhidosis)
BOTULINUM TOXIN
Indication
Dosage Maximum Botox
Repeat Treatment in 12 months
Glabellar
40 units
4
Orbic Oculi, Platysma
30 units
4
Frontalis
25 units
4
DAO, Mentalis
10 units
4
Masseter
100 units
4
Peri Oral Rhytids, Bunny Lines
8 units
4
OTHER S4 DRUGS
Name
Dosage Maximum
Drug
Repeat Treatment in 12 months
Hyaluronic Acid
6 mls per session
HA
6
Hyalase
1 Amp per tx & report to
prescribing Dr
Hyaluronidase
As per prescribing Dr
PRE-TREATMENT QUESTIONS
Are you allergic to anything?
Yes
No
Do you suffer from epilepsy?
Yes
No
Have you ever had a dental block before?
Yes
No
Any side effects?
Yes
No
Do you have a history of cold sores?
Yes
No
Do you smoke?
First Choice
Second Choice
Third Choice
Any serious health problems/major surgery?
First Choice
Second Choice
Third Choice
Medications – Medical/Herbal/Aspirin/Disprin/Nurofen?
First Choice
Second Choice
Third Choice
Are you pregnant or planning to be?
First Choice
Second Choice
Third Choice
Are you breast feeding?
First Choice
Second Choice
Third Choice
Have you or are you using Retin A/Roaccutane/Alpha Hydroxy Acid?
Yes
No
When
MM slash DD slash YYYY
Have you ever had Botox before?
Yes
No
When
MM slash DD slash YYYY
What area of the face?
Any side effects?
Have you ever had Dermal Fillers before? Eg: Restylane/Aquamid/Collagen?
Yes
No
When
MM slash DD slash YYYY
What area of the face?
Any side effects?
Have you ever had Cosmetic Surgery before?
Yes
No
What area of the body?
Do you bruise easily?
Yes
No
Have you had a Tetanus shot in the last 6 weeks
Yes
No
I confirm to the very best of my knowledge that the answers I have given above are correct and that I have not withheld any information that may be relevant to my treatment.
Client name:
(Required)
Client signature:
(Required)
