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Last Name
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Address, City, State, Zip
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MA: Wilmington/N. Reading Area
MA: Stoneham/Woburn Area
RI: Attleboro/ E. Providence Area
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Tell us a little about what service/issue(s) you would like to discuss:
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Laser and Medical History Snapshot
Do you have any Medical Conditions? Please list.
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What medications do you take & for what condition.
Are you ALLERGIC to any medications? Especially lidocaine or epinephrineor fish allergies ? Please list:
Do you have any metal implants? If so, where?
Have you ever used Accutane? If so, when was the last time?
Are you currently under the care of an MD? If so, for what reason?
Have you had any laser or Botox/Filler products before? If so, please list what service/product and last treatment.
Thank you! We'll be in touch shortly!!
Patient Photo: Please provide a close up face photo for your patient records. It is strictly confidential.
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