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Cosmetic Visit Form
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Preferred Pharmacy
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How did you hear about our practice?
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Pertinent Medical History (check all that apply)
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Cold Sores
Staph Infections
Autoimmune Disorder
Raised Scarring
Bleeding Disorder
Eczema / Dermatitis
Implants
Metal Pins/Plates/Wiring
Pace Maker
Poor Healing
Other
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Please list your history of cosmetic procedures, including any adverse reactions. If you have not had any cosmetic procedures, please enter "N/A" below.
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Please list all skin care and makeup products that you are currently using, including history of any product reactions. If none, please enter "N/A" into the space below.
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Please indicate your cosmetic concerns (if multiple selections, please indicate your primary concern in the field below for today’s discussion – a separate visit may be needed to address multiple concerns).
*
fine lines / wrinkles
acne
scarring
discoloration
brown spots
red spots
general redness
veins
uneven texture
bumps
unwanted hair
thinning lashes
general skin health
sagging / lax skiin
thin lips
double chin
facial volume loss
sensitivity
dandruff / scalp buildup
oiliness
dryness
ingrown hair
thinning / brittle hair
thin / sagging earlobes
aging hands
other
Primary Cosmetic Concern
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