MEDICAL FORM | Yasmin Kitchen Aesthetics

Please fill in this required medical form before you arrive for your treatment.

Medical Form

First name

Last name

Phone

Birthday

Day

Month

Year

Do you have any existing medical conditions?

If yes please state below otherwise write N/A

Are you currently taking any medication?

If yes please state below otherwise write N/A

Do you have any allergies or have you ever had anaphylaxis?

If yes please state below otherwise write N/A

Are you pregnant or breastfeeding?

If yes please state below otherwise write N/A

Do you have any skin conditions?

If yes please state below otherwise write N/A

Do you have any active infection at the intended site of procedure?

If yes please state below otherwise write N/A

By signing this document, I confirm I have answered all questions honestly and to the best of my knowledge. Yasmin Kitchen Aesthetics will not be liable for any injury or reaction relating to the services provided for any false information given.

Signature

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