aestheticCOACH 1 B, Rathbourne Avenue, Ashtown, Dublin, D15HYO4, Ireland

Medical History and Consent Form

Please note that this medical consent form will be kept confidential and will only be viewed by the Aesthetic Practitioner and clinic team responsible for you whilst undergoing treatment at this Cosmetic Injectables clinic. Your details will not be available to third parties and are stored securely.

If any of the answers on this consent form raise concern for your Aesthetics Practitioner you may be contacted to discuss further or alternatively, these may be discussed at the time of your consultation.

Patient Details
Medical History

Are you attending or receiving treatment from a doctor or specialist?

Are you taking any medication, or herbal remedies (including Antibiotics, Anticoagulants, Muscle Relaxants, St. Johns Wart, Roaccutane)?

Are you taking blood thinning medication (Aspirin, Plavix, Warfarin)?

Are you allergic to local anaesthetic injections, lignocaine, adrenaline or EMLA/ANESTOP/LMX4 cream?

Do you have any known allergies or a history of anaphylaxis (a life-threatening allergic reaction)?

Have you suffered from or had any of the following conditions?

Heart problems including an irregular heartbeat or angina

High or Low Blood Pressure or circulation problems including Raynaud’s Syndrome


Blood disorders/leukaemia/lymphoma/anaemia/cancer

Autoimmune disease, arthritis or recurrent sore throat.


Contact Dermatitis/Eczema

Keloids (hypertrophic scarring) or recent scar tissue (6 months) This is more common in dark-skinned individuals. See here for a picture

Easy bruising

Cold Sores

Psychiatric Illness/Depression

Do you use sunbeds or sunbathe?

Do you play a woodwind or brass instrument? (Because Botulinum Toxin softens wrinkles through its effect on muscles, it is important that you avoid treatment with Botulinum Toxin around the mouth if you play either of these families of instruments).

Are you pregnant/planning pregnancy/engaged in IVF treatment or are you breast-feeding?

Have you had a consultation or been treated with dermal filler, Botulinum Toxin, laser, chemical peels or microderm abraision before?

Have you had an allergic reaction to any dermal filler or Botulinum Toxin product?

Have you had a consultation or had plastic surgery of the face or neck or are you planning to have surgery?


Before and after photos are always taken to help assess treatment — these are confidential. However, I give my written consent for my photos to be used to show to future patients, and for marketing purposes.


See the available treatments in the photo at the top of this page. Please ask your practitioner if you would like to discuss a treatment which isn’t mentioned above.

I hereby consent to the following:

I have no known allergy to local anaesthetic cream or injections and understand that either or both may be required as part of my treatment.

In having treatments from the treatment provider, I consent to have my aesthetic records maintained for 10 years which is a requirement from insurance companies for all providers of aesthetic procedures.
Any details stored will be done so securely and not used for marketing purposes or any other purpose without prior consent.
This information is maintained under article 9(2) of the GDPR for these reasons:

  • the establishment, exercise or defence of legal claims as necessary.
  • the processing is necessary for public health purposes in the public interest (e.g. protecting against serious cross-border threats to health, or ensuring high standards of quality and safety of health care and of medicinal products or medical devices)

I have been informed about the risks and possible side effects of treatment and accept these risks as my own. I have understood and correctly completed the medical history form.

An undesired cosmetic effect, such as an unexpected appearance after treatment, can usually be avoided by clear communication between patient and Healthcare Professional.

Patient Signature

Consent to send Automated Treatment Reminders and to stay in touch

The treatment provider and Flourish would like to maintain a secure record of your: name, email, phone number and last treatments undertaken. This is to send out an automated reminder from the treatment provider to advise when your treatment may start to wear off and to offer a new appointment. We would also like to be able to stay in touch to provide you with information from the treatment provider about promotions or other treatments available. This information will not be shared with any party not named above. You have the right to remove consent for this at any stage by notifying the treatment provider or by opting out at the bottom of any emails from the treatment provider.

By submitting this form you are consenting to store your data privately on our system. Your private data will be held in accordance with data protection regulations.