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Medical History Form <br /> Today's Date: / / Birth Date: <br /> Name: <br /> Home Address: <br /> Work Address: <br /> Home Phone: ( ) Work Phone: ( ) <br /> Are you now or have been under the care of a physician within the last 2 years? <br /> YES NO <br /> If yes, 1p ease provide Physician's Name,Address and phone number. <br /> Name: Address: <br /> Phone Number: ( ) <br /> Person to contact you in an Emergency: <br /> List ALL medications you are currently taking, if any, including Retin A, Glycolic Acid <br /> and Acutane: <br /> List any drug, makeup, skin or food allergies (i.e., soap or cleansing creams): <br /> Have you recently in undergone a skin peel: YES NO <br /> What products do you use for skin care? <br /> Do you have any requirement for antibiotics prior to surgery or dental procedure? <br /> YES NO <br /> Do you have a history of allergic reaction to Latex? YES NO <br /> Do you have a history of Cardiac Valve Disease? YES NO <br /> Color: <br /> Lot # <br /> Batch # <br /> Continue <br />