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Existing Clients - Health History *Updates Only*
Date
First Name
Last Name
DOB
Address
Address 1
Address 2
City
Zip / Postal Code
State / Province
Country
Phone
Email
Physician
Phone
Emergency Contact
Phone
Please answer thoroughly:
Please list any and all updates to your health, since your last visit
I understand that withholding information or providing misinformation may result in contraindications or irritation to the skin from treatments received. I am aware that is my responsibility to inform my skin care professional of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and the skin care professional from liability and assume full responsibility thereof.
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