First Name

Last Name

Phone *

Email *

Are you UNDER 18 years of age?

Yes

No

Are you pregnant or breastfeeding?

Yes

No

Are you under the influence of alcohol or drugs?

Yes

No

Is there any reason you may not be fit and well for the procedure?

Yes

No

Do you have an allergy to nickel?

Yes

No

Do you have an allergy to latex/plaster?

Yes

No

Have you had or are you planning any injectables, botox, fillers or chemical peels within the last/next 6 months?

Yes

No

Do you have any imminent holiday plans?

Yes

No

Do you suffer with keloid scarring?

Yes

No

Do you suffer with epilepsy?

Yes

No

Do you suffer from Haemophillia?

Yes

No

Do you have any infectious diseases?

Yes

No

Do you have hepatitis C?

Yes

No

Do you suffer from shingles?

Yes

No

Do you suffer from psoriasis, blisters or skin disorders in this area?

Yes

No

Are you diabetic?

Yes

No

Do you have any respiratory problems?

Yes

No

Do you take any blood thinners?

Yes

No

Do you take Antabuse or Roaccutane?

Yes

No

Do you have high or low blood pressure?

Yes

No

Are you currently taking any medication?

Yes

No

Are you 5 weeks pre or post radio/chemotherapy?

Yes

No

Are you allergic to any local anaesthetics?

Yes

No

Are you currently using retinol containing products?

Yes

No

If you answered YES to any of the above contraindications please detail below

Please follow the link for PRE and POST aftercare - https://sarahgwenpmu.com/pre-post-treatment

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