Star Clinics Medical Form

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STAR CLINICS is an innovative laser, skin & body cosmetic clinic located in Keiraville, New South Wales. We provide high-end, non-invasive cosmetic services combined with our STAR BAR; an exclusive in-chair express beauty boutique, giving you the complete STAR experience.

Our commitment is to being an innovative cosmetic company, dedicated to improving skin health and quality of life. We use a treatment and results structure focusing on identifying the cause of skin and body concerns.    

Our work and research is driven by scientific principles and excellence, attaining the highest cosmetic practices, policies and procedural standards, in a working culture of integrity, pride and dedication, in doing so, creating value and results for clients. 

We pride ourselves on providing free education and professional advice on all the latest and greatest trends so that you can be assured that your treatment is right for you. 

As a pre-requisite to your first treatment, we require you to fill out your medical history below.

STAR CLINICS is an innovative laser, skin & body cosmetic clinic. We provide high end non invasive cosmetic services combined with our STAR BAR, an exclusive express in chair beauty boutique, giving you the complete STAR experience.

Our commitment is to being an innovative cosmetic company, dedicated to improving skin health and quality of life. We use a treatment and results structure focusing on identifying the cause of skin and body concerns.

As a pre-requisite to your first treatment, we require you to fill out your medical history below.

Personal Details

Medical Conditions

Diabetes/low blood glucose level
Asthma/lung disease
Respiratory Problem
Stroke
Heart Condition/Pace Maker
High Blood Pressure
Low Blood Pressure
High Cholestorol
Blood Clots/Clotting Disorder
Anaemia
Heart Burn/Reflux
Cold Sore/Herpes/Shingles
Hepatitis/HIV
Kidney Disease
Liver Disease
Hormone Imbalance/Thyroid
Epilepsy
Phobias/Mental Health Condition/Depression
Keloid Scarring
Skin Cancer/Cancer
Chemotherapy/Radiation Therapy
Have you undergone surgery within the last 12 months?
Allergies (medications, food, latex, other)
Other Medical Conditions

Medical Care

Do you have medical cover? If so who are you insured with?

Do you utilise of any of the following medical services?

Female clients only

Oral Contraceptive/Contraceptive implant (Mirena etc)
Trying to Fall Pregnant/Pregnant/Lactating
Polycystic Ovarian Syndrome
Have you been or are you going through Menopause?
Are your menstrual periods regular?

Hair and Skin

Do you suffer from ingrown hairs?
Do you experience excessive hair growth?
Eye Infections/Sensitive Eyes/Contact Lenses
Do you have an permanent makeup, implants and/or tattoos? Please list locations

Medications and Medical Treatment Devices

Prescriptions
Natural Supplements
Metal Plates/Pins/Implants
Have you taken Accutane or anticoagulents in the last 6 months?
Current Medications

Medical care

Do you presently engage the services of any of the following:

General Practitioner (GP)
Medical Specialist
Cosmetic/Plastic Surgeon

Lifestyle Factors

Are you a Smoker? How many per day?
How often do you drink alcohol?
How much caffeine do you consume?
Do you drink water regularly? If so how much?
Do you exercise? If so, how much and what type? eg: Gym member, sport etc.
Do you have a healthy diet? General breakfast, lunch and dinner, Fast food, snacks, soft drink etc.

Skin Treatment History

Cosmetic Surgery
Botox
Dermal Fillers
Fractional Laser
Laser/IPL
Facials
Microdermabrasion
Peels
Needling
Vascular Treatments
Other

Skin and Body Products

Do you use skin care or body products at home?

Basic Facial & Skin Analysis

Do you believe you may have any of the following skin conditions?

Religious Beliefs

Do you have religious beliefs that may need to be taken into account during your treatment?

Client Concerns

Please provide any information that might assist in your diagnosis and preparation of care plan

Client Information & Photo Consent

Your personal information and photos are collected and recorded by STAR CLINICS Pty Ltd in order to best manage your treatment outcomes. All personal information will be kept securely in your personal file and/or secure server. This information is solely for the use of STAR CLINICS Pty Ltd and will not be disclosed to any other entity without your written consent.

By clicking the checkbox below, I certify that I have given consent and have provided correct information above.

I understand and agree to pay all fees related to STAR CLINICS services.

You are entering into an agreement with STAR CLINICS to maintain your appointments otherwise fees and charges will apply.