Hair Loss Consultation
Complete this online before PRP, PRF, microneedling or combined hair loss treatments.
Complete Hair Form OnlineAngel Hands Aesthetics • Consultation Forms
Consultation forms
Printable forms for selected treatments. These help the clinic check suitability, safety and treatment goals before treatment.
Complete online
Submit consultation forms digitally.
Fat Dissolving Consultation
Complete this online before Lemon Bottle or Aqualyx treatment.
Complete Fat Dissolving Form OnlineDownloadable forms
Download and print consultation forms.
Hair Loss Consultation Form
For PRP, PRF, microneedling or combined hair loss treatments.
Download Hair Loss FormInjectable Fat Dissolving Consultation Form
For Lemon Bottle and Aqualyx treatment consultations.
Download Fat Dissolving FormHair Loss Treatment Consultation Form
For PRP, PRF, Microneedling or combined treatments
Section 1: Client personal details
All information is kept strictly confidential.
Full Name: _________________________________________________Date of Birth: ____________________Contact Number: ____________________Email Address: ______________________________________________Address: ____________________________________________________How did you hear about us? Google Social Media Recommendation Other: _______________
Section 2: Hair history and concerns
1. What is your main concern regarding your hair?__________________________________________________________________
2. When did you first notice hair loss or thinning? Less than 6 months ago 6 months–1 year ago 1–3 years ago More than 3 years ago
3. Which areas are affected? Front hairline Top/crown Temples Whole scalp Other: _______________
4. Has anyone in your immediate family experienced hair loss? Yes No Not sureIf yes, please specify relationship: ____________________
5. Have you had any previous treatments for hair loss? Yes NoIf yes, please list what you had, when, and results: _________________________________
6. Do you currently use any products for your hair/scalp? Yes NoIf yes, please list: ______________________________________________
Section 3: Medical history
This helps us check if treatment is safe and suitable for you.
| Question | Yes | No |
|---|---|---|
| Do you have any bleeding disorders or blood clotting problems? | ||
| Are you taking any blood-thinning medication such as warfarin, aspirin or clopidogrel? | ||
| Do you have diabetes? | ||
| Do you have a history of cancer or current cancer treatment? | ||
| Do you have any autoimmune conditions? | ||
| Do you have any infections, skin conditions or scars on your scalp? | ||
| Are you pregnant, breastfeeding or planning to become pregnant? | ||
| Do you have allergies to any medications or products? | ||
| Have you had any major surgery in the last 6 months? | ||
| Do you smoke or drink alcohol regularly? |
Please list any other medical conditions or medications you are taking:
__________________________________________________________________
Section 4: Treatment explanation and understanding
Tick the one you are having, or all if combined.
- PRP – Blood is taken, spun to separate growth-factor-rich plasma, then injected into the scalp.
- PRF – Similar to PRP but prepared without additives, forming a natural gel that releases growth factors more slowly.
- Microneedling – Tiny needles create small channels in the scalp to boost natural healing and support product absorption.
Expected results
- Results vary from person to person.
- Most treatments need 3–4 sessions spaced 4–6 weeks apart.
- Best results are usually seen 3–6 months after starting.
- Maintenance sessions may be needed.
Possible risks and side effects
- Mild redness, swelling or tenderness.
- Small bruises or tiny scabs.
- Very rarely, temporary irritation or infection.
Aftercare instructions
- Avoid washing hair for 24 hours.
- Avoid heat, steam, saunas or strenuous exercise for 48 hours.
- Do not apply hair products directly to treated areas for 24 hours.
- Keep scalp clean and moisturised as advised.
Section 5: Consultation outcome
Assessment by Practitioner: _________________________________________Recommendation: Suitable – proceed Further tests/information needed Not suitable – alternative options discussedType of treatment: ____________________Number of sessions: _______Time between sessions: _______ weeksCost per session: £_______Total cost: £_______
Section 6: Client consent
I confirm that I have read and understood all the information above. I understand the nature of the treatment, what to expect, possible risks and results. I agree to proceed as discussed.
Client Signature: ______________________________Date: ____________________Practitioner Name: Dolores BishopPractitioner Signature: ________________________Date: ____________________
Injectable Fat Dissolving Consultation Form
For Lemon Bottle and Aqualyx
Section 1: Client personal details
All information is kept strictly confidential.
Full Name: _________________________________________________Date of Birth: ____________________Contact Number: ____________________Email Address: ______________________________________________Address: ____________________________________________________How did you hear about us? Google Social Media Recommendation Flyer Other: _______________
Section 2: Treatment selection and goals
Product: Lemon Bottle Aqualyx
Area(s): Double Chin / Jawline Abdomen / Tummy Love Handles / Waist Bum / Hips Inner Thighs Outer Thighs Inner Knees Back / Bra Line Upper Arms / Bingo Wings Other: ____________________
Main concern / what would you like to improve? _________________________________Ideal result: ______________________________________________Current measurements / photo reference taken: Yes NoPrevious fat dissolving or similar treatments? Yes NoSurgery, liposuction or injury in treatment area in last 12 months? Yes NoCurrently following diet or exercise programme? Yes No Not sure
Section 3: Medical history
Please answer honestly.
| Question | Yes | No |
|---|---|---|
| Do you have poor circulation, blood clots or history of DVT? | ||
| Do you have diabetes, heart conditions, high or low blood pressure? | ||
| Do you have any autoimmune conditions or immune system disorders? | ||
| Do you have liver or kidney disease / reduced liver or kidney function? | ||
| Do you have any skin infections, open wounds, eczema, psoriasis or scars in the treatment area? | ||
| Do you have a history of keloid scarring or abnormal healing? | ||
| Are you pregnant, breastfeeding or planning to become pregnant? | ||
| Do you have any allergies, especially to soya, phosphatidylcholine, deoxycholic acid or product ingredients? | ||
| Are you allergic to local anaesthetic / lidocaine? | ||
| Do you suffer from nerve conditions or numbness in the area to be treated? | ||
| Have you had any vaccination in the face/body area within the last 2 weeks? | ||
| Do you smoke or drink alcohol regularly? | ||
| Are you taking any medication, supplements or anti-inflammatory drugs? |
Please list any other health issues or details we should know:
__________________________________________________________________
Section 4: Treatment information and what to expect
How the treatments work
- Lemon Bottle is used to support fat reduction, skin firming and skin texture.
- Aqualyx targets small stubborn pockets of fat. The body then processes the treated fat naturally.
- Both are injected into the fatty area using fine needles.
Recommended treatment plan
- Most areas require 2–4 sessions.
- Sessions are spaced 2–4 weeks apart.
- Each session takes around 30–45 minutes depending on area size.
- Results usually develop over 2–6 weeks.
Possible risks and side effects
- Swelling, redness, bruising or tenderness at injection sites.
- Mild pain, stinging or burning sensation.
- Hardness or lumpy feeling, mild itching or warmth.
- Rarely, infection, uneven results or scarring.
Aftercare instructions
- Drink 2 litres of water every day for 3 days.
- Massage gently twice a day for 5 minutes if advised.
- Avoid alcohol and caffeine for 48 hours.
- Avoid hot baths, saunas, steam rooms, sunbeds or heat packs for 72 hours.
- Avoid heavy exercise for 48 hours.
- Contact the clinic if you have extreme pain, severe swelling or fever.
Section 5: Consultation outcome
Practitioner Assessment: _________________________________________Recommendation: Suitable – proceed Further information/tests needed Not suitable Alternative treatment recommendedProduct to use: ____________________Area(s) to treat: ____________________Number of sessions: _______Time between sessions: _______ weeksCost per session: £_______Total course cost: £_______
Section 6: Client consent
I confirm that all medical information I have given is true and correct. I understand how the treatment works, that results vary, and that I have been informed of possible risks, side effects and aftercare rules. I agree to proceed with the treatment plan as discussed.
Client Signature: ______________________________Date: ____________________Practitioner Name: Dolores BishopPractitioner Signature: ________________________Date: ____________________