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How did you hear about us?
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Employer
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Occupation:
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Ok to leave a message on mobile phone?
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Your Pharmacy:
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Phone:
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Address:
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City
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Medical History
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Which of the following best describes your skin
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Medical Conditions – Past or Current
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If Hepatitis, type
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Other Factors That Could Affect your Treatment
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Are you pregnant?
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Trying to become pregnant?
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Are you nursing?
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Are you claustrophobic?
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Do you smoke?
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Do you drink alcohol?
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Amount:
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Do you use illicit drugs?
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Type
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Have you been diagnosed with?
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Other (Specify):
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Take Coumadin/daily Aspirin/blood thinners?
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Have prolonged exposure to the sun?
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Do you use daily sunscreen?
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On any mood altering/anti-depression medication
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If yes which one
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Cosmetic procedures in past:
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Surgeries procedure in past:
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Information you feel will assist in evaluation
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I would like a FREE Visia Skin Analysis/Consult
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I am interested in
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My Concerns are:
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Other
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For office use only
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TREATMENT
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PRODUCT
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INJECTABLE
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eligible for the treatments/products above
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All above are authorized treatment protocols
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reviewed patient’s allergies medication/past med
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Notes
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