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Model Form

First Name

Last Name

Email

Phone

Date of Birth

Address

Medical Questionnaire

Taking any medications

Allergies

Breast feeding

Pregnant

Heart disease/ angina

Thyriod problems

Auto-immune disease

Arthritis

Asthma/bronchitis

Convulsions

Depression

High/low blood pressure

Facial cold sores

Diabetes

Stomach ulcer/colitis

Skin disease (herpes/acne)

HIV/hepatitis

Glucoma/cataract

Venereal disease

Bells/facial palsy

Phlebitis

Hypoglycaemia

Allergies or anaphylaxis to Botox

Myasthenia gravis or Eaton Lambert syndrome

History of anaphylaxis

If ticked yes to any of the above please specify here

Which treatment/treatments are you interested in being a model for?

Have you had this treatment previously?

If yes please specify how often and how long ago

Are you currently recieving any medical treatment?

Thank you for completing this form, we will contact you when we have model opportunities. The medical questionnaire is to determine whether you are suitable for the treatment.

Subscribe Form

Thanks for submitting!

Customer Service email address - admin@theeliteclinic.com

Customer Service number - 01564664004

2 Milverton Villas, 2 Wilsons Rd, Solihull B93 0HZ

©2020 by Elite Aesthetics Solihull. The Elite Clinic is a trading name of 'Elite Aesthetics Solihull'
Registered name - 'Elite Aesthetics Solihull', Registered address - 2 Milverton villas. Knowle, B93 0HZ

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