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cAf(cr6b"4 b� jam <br /> a-el"�krt)a&a aM 4a <br /> Medical History Form (page 1 of 2) Today's Date <br /> Name <br /> Home Address <br /> City State Zip <br /> Phone# Alternate Phone# <br /> E-mail Address <br /> Occupation Birth date <br /> Referred by: <br /> Person to contact in case of emergency: Name <br /> Phone# <br /> Alt phone# <br /> Relationship <br /> Are you now or have you been under the care of a Physician within the last two years? (Circle <br /> One) Yes No <br /> If yes, please describe why <br /> If yes, please provide Physician name, address and phone number: <br /> List all medications you are currently taking, including Retin A, Glycolic Acid, Acutane, and/or <br /> Latesse: <br /> List all drug, make-up, skin or food allergies: <br /> Have you currently undergone a skin peel, laser treatment or light treatment? <br /> (Circle One) Yes No If yes, which one and when? <br /> 'Mat products do you use for your skin care regimen? <br /> Signature Date <br />