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C � (wreclwadinq l) yJealmi <br />Medical History Form (page 1 of 2) <br />Name <br />Home Address. <br />Citv <br />Phone # <br />E-mail Address <br />Occupation_ <br />Referred by: <br />State Zip <br />_ Alternate Phone # <br />Person to contact in case of emergency: Name_ <br />Phone #_ <br />Alt phone #_ <br />Relationship <br />Today's Date _/_/_ <br />Birth date I I <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 />What products do you use for your skin care regimen? <br />Signature Date <br />