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Name: Date of Birth: Phone Number: Email:
Please indicate if any of the following apply to you: PregnantBreast-feedingEpilepsySeizure disorderPhotosensitive (due to disorder or medication)Currently using steroids
Please provide information on any recent treatments you’ve received.
Botox (How recent?): Threads (How recent?): Fillers (How recent?): Facelift (How recent?):
Have you had any of the following treatments in the last month? Chemical PeelsLaser treatmentsMicrodermabrasion
List any prescription creams or oral medications provided by a dermatologist:
Check all that apply: Neck injuriesDental implantPregnantCancerLymph node removedVertigoPacemakerCold soresClaustrophobia
Please leave this field empty.
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