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c � �cr Nblac(�ru� ►n�- f cauui <br />Medical History Form (page 1 of 2) Today's Date _/_/_ <br />Name <br />Home Address <br />City <br />Phone # <br />E-mail Address <br />State Zip <br />Alternate Phone # <br />Occupation <br />Birth date ! / <br />Referred by: <br />Person to contact in case <br />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 />What products do you use for your skin care regimen? <br />Signature Date <br />