Strathearn Health and Beauty PRP Questionnaire

Patient Details

YesNo NoYes
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Emergency Contact Details

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Patient GP Details

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We recommend to all our patients that their relevant medical professional i.e. GP should be informed about the treatment.  In certain circumstances, Strathearn Health & Beauty may contact your GP or medical professional regarding your treatment.

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Your Medical History

Have you ever suffered from any of the following? (Please tick all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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YesNo NoYes
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YesNo NoYes
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Have you been prescribed any of the following? (Please tick all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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YesNo NoYes
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Please list your current medications:

Medication Name
Dosage
what is it used to treat?
Date of last dose?
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Medical Investigations/Operations

Condition or Illness
Treatment Received
Treatment Date
Are you due a follow up?
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YesNo NoYes
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YesNo NoYes
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Patient Consent to Lesion Removal

By signing below the patient confirms that they:

  • Consent to PRP Hair procedure as described by the practitioner.
  • Agree to follow all pre and post care instructions which will be fully explained, and a copy suppled to the patient.
  • Consent to the taking and storing of photographs with the understanding that they will be used ONLY for the purpose of the treatment.
  • Consent to allow Strathearn Health and Beauty to contact the patient’s GP or healthcare provider regarding the procedure if deemed necessary and/or appropriate by the performing surgeon.
  • I understand that the results of this treatment vary considerably and a small percentage of people may not respond to the treatment.
  • I understand that multiple treatments will be required to achieve satisfactory results.
  • I understand that there may be some short-term side effects such as reddening of thie skin, bruising and swelling.
  • I understand that local anaesthetic may be used during the course of my treatment.
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By clicking “Submit” you are agreeing to all Strathearn Health and Beauty Terms & Conditions and declare that all supplied information is accurate and up to date.

Strathearn Health and Beauty PRP Questionnaire

Strathearn Health and Beauty PRP Questionnaire

Patient Details

Are you currently Pregnant?   {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Mobile Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Occupation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Emergency Contact Details

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Relationship to Patient {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient GP Details

GP's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Surgery/Practice Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Surgery Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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We recommend to all our patients that their relevant medical professional i.e. GP should be informed about the treatment.  In certain circumstances, Strathearn Health & Beauty may contact your GP or medical professional regarding your treatment.

How did you hear about us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please Specify {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Your Medical History

Have you ever suffered from any of the following? (Please tick all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please Describe {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you taking medication for the above condition? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have any allergies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes please describe {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you been prescribed any of the following? (Please tick all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What condition was this used to treat? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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When did you last take a dose? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you currently taking any other medications or herbal supplements? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please list your current medications:

Medication Name
Dosage
what is it used to treat?
Date of last dose?
Medication {binding ItemNumber}
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Dosage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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what is it used to treat? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date of last dose? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please Tick if any of the following applies to you:   {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Location of Plates/Pins {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical Investigations/Operations

Condition or Illness
Treatment Received
Treatment Date
Are you due a follow up?
Item {binding ItemNumber}
Condition or Illness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Treatment Received {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Treatment Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you due a follow up? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do You smoke? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do You Drink Alcohol? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many cigarettes would you smoke in an average day? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many units of alcohol would you consume in an week? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Consent to Lesion Removal

By signing below the patient confirms that they:

  • Consent to PRP Hair procedure as described by the practitioner.
  • Agree to follow all pre and post care instructions which will be fully explained, and a copy suppled to the patient.
  • Consent to the taking and storing of photographs with the understanding that they will be used ONLY for the purpose of the treatment.
  • Consent to allow Strathearn Health and Beauty to contact the patient’s GP or healthcare provider regarding the procedure if deemed necessary and/or appropriate by the performing surgeon.
  • I understand that the results of this treatment vary considerably and a small percentage of people may not respond to the treatment.
  • I understand that multiple treatments will be required to achieve satisfactory results.
  • I understand that there may be some short-term side effects such as reddening of thie skin, bruising and swelling.
  • I understand that local anaesthetic may be used during the course of my treatment.
Patient Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please specify the location of the Area to be treated: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please use the button below to upload any photos of the treatment area and/or any relevant letters from GP or health professionals. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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By clicking “Submit” you are agreeing to all Strathearn Health and Beauty Terms & Conditions and declare that all supplied information is accurate and up to date.