Medical info

Full Name *

Email *

Phone Number *

Date of Birth *

Gender *

• Female
• Male

Are you taking any kind of medication topical or oral? *

• Yes
• No

Medical Story

Allergies

Are you pregnant? *

• Yes
• No

Do you have any surgery? *

• Yes
• No

More details

Do you have metal implants in any part of your body? *

• Yes
• No

More details

Do you have a pacemaker? *

• Yes
• No

Have you received botulinum toxin? *

• Yes
• No

Date of last one

Have you received dermal fillers? *

• Yes
• No

Date

What kind?

Send

Covid-19 Health Declaration

Full name *

Email *

• My body temperature is lower than 98.6°F / 37.5°C
• I am not experiencing the symptoms: fever, cough, sore throat, shortness of breath.
• I haven´t been in close contact with a covid-19 patient in the last 14 days.

Initials *

Date *

• I declare that the info I´ve provided is accurate & complete

Send

Reservations

Do you want to make an appointment?

Book now