PERFECTION HAIR UK LTD

office;7 Buttermere, Liden, Swindon , Wilts, England, SN3 6LF.

Tel 01793 524660 (24 hr) or 0589 499148

Senior Consultant Dr M Ross PhD (Master Craftsman)

MEDICAL INFORMATION

Name…..

Address……

Telephone Number…..

Date of Birth…..

Single/Divorced/Married…

Occupation…….

Name and Address of your doctor (surgery only)…….

Details of any medicines currently being taken……….

Have you ever had any reaction to anaesthetic (surgery only)…….

Are you allergic to any medicines, Tablets, Plasters, etc (surgery only)……..

Do you have any Allergies……

Do you take Aspirin or and medicine containing Aspirin…….

Do you have high or low blood pressure…….

Blood Pressure taken by…….

Date…

Reading..

Have you had;
Asthma/bronchitis
Fits, faints or blackouts
Heart Disease
Diabetes
Bleeding tendencies or disorders……….

I declare that the above answers are correct and accurate, and that I consent to go on the hair rejuvenation program including if required the use of minoxidil or finasteride;

Signed

Full Name

Date