cosmetic acupuncture & micro-needling

Pre- Appointment Questionnaire

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1. Name *
1. Name
2. Date Of Birth *
2. Date Of Birth
Past or current medical problems
Please tick all that apply and / or use the text box below
If yes to any medical problems, please provide details
Skin Health
Please tick all that apply and/or use the text box below
If yes to any skin problems, please provide details.
Please specify any regular medication including supplements or oral contraceptive pill
Medications / Food / Latex / Environmental (dust, pollen etc)
Declaration *
I hereby understand that Acupuncture/ Microneedling maybe contra-indicated for certain conditions and therefore I have fully disclosed my medical history to my practitioner.