EFTA00314098.pdf

4. Please Indicate which, if any, cosmetic treatments you have done in the past. Be sure to include date of the last treatment and your level of satisfaction with results. J Microdermabrasion J Skin tightening laser (list which type) Chemical peels (please list which type) J IPL J Botox 3 Laser hair removal J Dermal fillers Cosmetic surgery 3 Photorejuvenating laser (list which type) J Body contouring/fat reduction treatment (list which type) 5. Please list your full AM & PM skincare - 6. Please provide the name and contact regimen. information of your primary physician. Name: PM. Phone number: 7. Please indicate who referred you to our n 8. Please list any medications, prescriptions or practice. supplements you are currently taking. 9. Please list any allergies to medications. 10. Are you pregnant, planning on becoming pregnant or breast feeding? 6. Please provide current pharmacy information including address, phone number and fax number.' EvS.57tn Street d Eroacway. 212 - :came, Fa. (21; ass sass VITA\CAL-Ti-A I prior-) e OT AVG:. FAX 100 4C • This information is raquirrid rota •-iMiirr•WICY OrMaintiont EFTA00314098