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FACEmed Medical History Questionnaire

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FACEmed Medical History Questionnaire

Please fill out the form below

Name
First Last
Date of Birth
DD slash MM slash YYYY
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Email
Home Phone
Mobile
Occupation*
Ethnicity
Do you have or have you suffered from any of the following
Heart Complaints e.g. heart attack, angina, surgery, AF, Pacemaker*
- Yes
- No
Rheumatic fever*
- Yes
- No
Diabetes*
- Yes
- No
Chronic bronchitis, asthma or previous TB or respiratory illness*
- Yes
- No
Epilepsy, fainting episodes or neuro-surgery*
- Yes
- No
Depression/Anxiety or any psychiatric illness*
- Yes
- No
Excessive bleeding or easily bruised*
- Yes
- No
Reaction to local anesthetic*
- Yes
- No
High / Low blood pressure*
- Yes
- No
Are you or could you be pregnant at present*
- Yes
- No
Have you been treated with hydrocortisone or cortico-steroids*
- Yes
- No
Do you carry a medical warning card*
- Yes
- No
In the past have you had any surgeries*
- Yes
- No
Any other serious illness not mentioned above*
- Yes
- No
Do you have any allergies to medicines or anything else*
- Yes
- No
Are you HIV positive*
- Yes
- No
Have you ever been diagnosed with Hepatitis?*
- Yes
- No
Investigated for any blood borne or infectious diseases*
- Yes
- No
Any dermatological-skin/scalp conditions (eczema/psoriasis) / Alopecia*
- Yes
- No
Any recent injuries/accidents (fracture or muscular injuries)*
- Yes
- No
If you answered yes to any of the previous questions, please explain the details below:
Are you at present taking any medication?*
- Yes
- No
if so please state name and dose:
Your approximate Weight
Your weekly alcohol consumption? (Units)
If you smoke on average how many cigarettes do you have a day
Do you have any health concerns or conditions that you would like to notify us about?
Name & Address of your GP
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
NHS Number
NB: Please keep us informed of any changes to your health.
I opt-in to receive communication from FACEmed such as appointment reminders, important notifications and Centre news.*
- Yes
- No
Please agree with the FACEmed Privacy Statement.*
- I agree with the FACEmed Privacy Statement
To view our Privacy Statement Click here

Telephone:

01268 833680

Email:

enquiries@nullfacemed.co.uk

Address:

FACEmed Cosmetic Medical & Dental Centre
Crays Hill
Billericay
Essex
CM11 2XP

Call 01268 833 680

AREAS OF EXPERTISE

Dentistry
Surgical Procedures
Cosmetic & Medical Injectables
Aesthetic Treatments and Skincare

INSTAGRAM

Non-Surgical Browlift! Looking for a subtle enhan

Non-Surgical Browlift!
Looking for a subtle enhancement with the greatest impact? The non-surgical browlift with muscle relaxants is an innovative procedure offering a natural looking lift to your eyebrows, leaving you with a refreshed and youthful appearance.
By strategically injecting muscle relaxants, we target specific muscles to gently lift your brows, reducing sagging and wrinkles. The result? A rejuvenated look without the need for surgery!
Benefits you'll love:
Natural looking results
Minimal downtime
Quick and convenient
Versatility tailored to your needs

Book your complimentary initial assessment on 01268833680 or email hello@facemed.co.uk
#facesbymon #FACEmed #musclerelaxants #aesthetics #Billericay #Brentwood #Essex #Browlift #nonsurgicalbrowlift #injectables #Youthfullglow

The Magic at FACEmed really happens when our multi

The Magic at FACEmed really happens when our multidisciplinary teams work together to give patients the best outcome possible. Thank you to our lovely patient for allowing us to show the results of her upper eyelid surgery combined with ongoing muscle relaxant injections. A true success story from the Surgical and Medical Aesthetic teams working together.
Book your complimentary initial assessment on 01268833680 or email hello@facemed.co.uk
.
#aesthetics #surgery #facemed #essex #eyelidsurgery #aestheticinjectables #wrinklereduction #billericay #medicalonly #browlift #facelift #blepharoplasty

FRESH FRIDAY FEELING 💫🦷🪄🪥 come watch o

FRESH FRIDAY FEELING 💫🦷🪄🪥 come watch our Hygienist @smiles_by_alysha in action!

Save yourself from future dental problems by seeing a Dental Hygienist regularly.

Have you had professional Hygiene therapy in the last six months?

Against a calming backdrop the experts work their

Against a calming backdrop the experts work their magic 🤍
Sitting quietly on the outskirts of Billericay Essex the talented team at FACEmed are restoring confidence and enhancing lives 🪄
.
.
#essexsurgery #essexdentistry #facemed #walkwithme #daysurgery #noflowerwalls

💜We’re proud to offer BlancOne®🦷, a revol

💜We’re proud to offer BlancOne®🦷, a revolutionary in-clinic teeth whitening system that can brighten your smile by up to 5 shades in just one session😍. BlancOne® is a safe and effective treatment that is perfect for patients who want to achieve a whiter smile without the hassle of at-home whitening kits.⭐
.
BlancONE in-surgery teeth whitening is ideal for an up coming event due to its instant results. 🤍🌟
☑️Fast results: See a brighter smile in as little as 10 minutes.
☑️Safe and effective: clinically proven treatment that is gentle on your teeth and gums.
☑️No sensitivity: formulated to minimise tooth sensitivity.
☑️Convenient: done in the comfort of the dental chair.

We offer a complimentary 20min smile assessment. Call us for more information on 01268 833680 or DM.

#facemed #blanconewhitening #brentwood #billericay #teethwhiting #instantresult #ConfidentSmile #SafeAndEffective #SmileTransformation #airflowdentaltreatment #brightsmile #gentledentalcare #dentalhygiene #stainremoval #oralhealth #teethcleaning #dentistessex #hygienistessex

🫦💉Revitalise your Lips with Injectable Lip H

🫦💉Revitalise your Lips with Injectable Lip Hydration Treatment😍💋
This non-invasive treatment offers a subtle yet effective way to achieve plump, hydrated lips.
Injectable lip hydration involves the use of hyaluronic acid based dermal fillers to enhance the volume and moisture levels in the lips. Hyaluronic acid is a naturally occurring substance in the body that plays a crucial role in maintaining skin hydration and elasticity. By introducing this hydrating substance into the lips through injections, the treatment provides a boost of moisture, resulting in plumper and more defined lips.

Benefits of injectable lip hydration treatment are natural-looking immediate results with minimal downtime.
•
•
•
Book your complimentary face assessment with Monica Berrange on 01268 833680 or DM us, limited spaces remaining for December.
#hyaluronicacid #facemed #nonsurgical #aesthetics #brentwood #billericay #facesbymon #enhanceyournaturalbeauty #aestheticsessex #nonsurgicalessex

Embrace the art of subtle transformation with non-

Embrace the art of subtle transformation with non-surgical injections using muscle relaxants 💉✨
•Botulinum Toxin works by temporarily relaxing the targeted muscles. In the case of brow asymmetry, the goal is often to adjust the activity of certain muscles to create balance and harmony.
•The effects of muscles relaxants take a few days to become noticeable, with full results typically visible within two weeks. The treatment provides a subtle and natural-looking correction to brow asymmetry.
•
•
•
Book your complimentary face assessment with Monica, limited December appointments remaining 🤍💜
#enhanceyournaturalbeauty #browtransformation #facesbymon #facemed
#subtlesymmetry #nonsurgical #aesthetics #ConfidenceBoost #essex #billericay #brentwood

Say goodbye to deep nasolabial and marionette line

Say goodbye to deep nasolabial and marionette lines and hello to a refreshed lower face with non-surgical injectable rejuvenation.
Prepare to look and feel your absolute best this upcoming festive season.
✨🥳💜🤩🎀
Monica Berrange offers complimentary new patient assessments, simply pop us a DM to enquire! #NaturalBeauty #YouthfulGlow #ConfidenceBoost #InjectableMagic #aesthetics #nonsurgical #facemed #aestheticsessex

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FACEmed LTD

FACEmed
Crays Hill
Billericay
Essex CM11 2XP

Registered in England & Wales Company No. 06682721

Opening Hours:
Mon – Fri 8am – 6pm
Sat 8am – 2pm

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