Due to Government regulations your Topical Anaesthetic (numbing cream) needs to be ordered and prescribed to you from the Pharmacist. Please fill out the form below and we will send it off to Tugun Compounding Pharmacy on your behalf.

PATIENT QUESTIONNAIRE & EVELUATION FORM

TUGUN COMPOUNDING PHARMACY

TOPICAL ANAESTHETIC

Date:

Full Name:

Address:

Mobile:

Email:

Procedure(s):

Site(s) to be

Treated:

Prior Procedures

Have you had adverse reactions to prior procedures and/or topical anaesthetics?

Have you had any of the following procedures in the last 2 weeks?

* Hair removal (plucking, waxing, electrolysis, threading ect)

*Cosmetic tattoo, tattoos

*Radio frequency (RF)

*Chemical peel

*Tanning bed, sun exposure

*Laser/IPL

*Microdermabrasion

*Plastic/cosmetic surgery

*Other

Medical History

Are you under Medical Supervision for, or have a history of the following?

*Please go over the below list carefully and if you answer yes to any of the questions please supply details at the bottom of this section.

Do you have life threatening allergies to anything?
Have you ever had a reaction to any topical anaesthetics (eg. Emla, LMX4, Xylocaine)?
Are you, or is it possible that you are pregnant?
Are you currently breast feeding?
Liver disease eg. Hepatitis
Atypical Pseudocholinesterase
Sulphonamide allergies
Congenital or idiopathic methemoglobinemia
Seizures
Cardiac conditions/arrhythmia (eg. blood pressure)
Asthma/respiratory
Auto-Immune conditions (eg. rheumatoid arthritis, scleroderma)
Disease of nerves or muscles
Glaucoma
Thyroid imbalance
Eczema
Active skin infections
Cold sores
Herpes
Shingles
Does your skin form thick or raised scars from cuts or bruises eg. keloid scarring?
After injury to the skin (eg. cuts, burns) do you have. Darkening of the skin in that area (hyperpigmentation), or Lightening of the skin in that area (hypopigmentation)?
Do you have a history of skin cancer or unusual moles?
Do you have moles that have changed, itched or bled?
Have you ever had a photosensitive disorder (eg. Lupus)?
Cancer
Diabetes
Haemophilia (easy bruising or bleeding)
Autoimmune conditions
HIV (human immunodeficiency virus)
Easy bruising or bleeding
Other conditions or health issues not listed

Medications

Are you currently taking any medications or supplements (prescription and non-prescription)?

Eg.    Name              Strength        Dose                Reason

          Telfast             180mg            One Daily        Sinus allergies

          Norvasc           5mg               One Daily        Blood pressure

          Vitamin C        500mg            Two Daily        General health

Topical Application to Treatment Area

Have you used any products on the area to be treated containing the following ingredients in the last 1-2 weeks?

* Retinoids (Vitamin A) eg. Tretinoin, Retinol

* Alpha Beta Hydroxy acids eg. glycolic acid, lactic acid, salicylic acid

*Benzoyl peroxide or Adapalene (Differin)

*Hydroquinone, azelaic acid, kojic acid

In the past have you had any adverse reactions to any of these or other skin products?

Acknowledgement and form Completion

To the best of my knowledge, I have answered every question completely and accurately.

The procedure has been explained to me and

* I will only apply the topical anaesthetic after checking in at the clinic for my procedure.

 

or

*I require clinician assistance in safe and appropriate application of the topical anaesthetic for this procedure.

I wish my compound/s to be delivered to:

I

authorise and consent my information to be disclosed to:

Tugun Compounding Pharmacy

Shop 2, 457 Golden Four Drive

Tugun QLD 4224

Phone: 07 5598 2411

Fax: 07 5598 3371

Email: tuguncom@bigpond.net.au

The information contained within this form is not, and is not intended to be, a substitute for direct communication between the clinician, pharmacist and patient.

By clicking submit below I acknowledge that I will be contacted by a pharmacist to determine the suitability, appropriate use and supply of the topical anaesthetic for my procedure.

Contact Details

Mobile - 0410 924 564

Email - info@chloeregan.com.au

Coolum Beach Wellness Hub

12 Williams St

Coolum Beach

Sunshine Coast QLD 4573

Chloe Regan Cosmetics & Tattooing © Copyright 2017 - ABN: 45 603 725 373  

Servicing clients in the Sunshine Coast area Queensland and Interstate - Noosa - Coolum - Peregian Springs - Peregian Beach - Maroochydore - Mooloolaba - Mount Coolum - Brisbane