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Medical History Form <br /> Today's ate® Birth Date: <br /> Name: <br /> Home ress® <br /> Work ress® <br /> Home one® L---I- or 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,p1wu provide Physician's Name,Address and phone number. <br /> Name: ress® <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 Ac tape® <br /> List any drug, makeup, skin orf allergies (i.e., soap or cleansing creams): <br /> Have you recently undergone a skin el® YFS 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 /> Batch #: <br /> Continue <br />