Date

Birthday

Do you understand the information you have been provided?*

Do you feel sufficient information has been provided to you to enable you to consent?*

Has you consent been given freely?*

Do you have any medical conditions?*

Are you pregnant or breast feeding?*

Do you have a neuromuscular dieases (e.g MS, ALS ect)*

Do you have an autoimmune disease? *

Do you have any skin conditions?*

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

Do you have any active infections at the site of procedure?*

Are you taking antibiotics or other prescription medications?*

Is there any other medical and/or social history that we should know about? If so please provide full details in the comments section at the bottom.*

Do you give consent for photos to be taken for promotion purposes?*

I will retain throughout the course of the procedure and refer to this as required*