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Birthday Date:
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2nd. Phone:
Address:
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Zip:
How can we help you today?
Do you have other questions you would like to ask or issues you want to discuss while you are here?
What changes and/or results would you like to see?
Surgical Procedures you have had:
Medicines you take or have taken:
Medical Conditions you have/have had:
Smoker?
Yes
No
Drug Allergies?
Yes
No
Do you get cold sores
Yes
No
Special Diet/Exercises Routine?
Number/Ages of Children :
Possibility of pregnancy?
Yes
No
How did you hear about Feel Beautiful Plastic Surgery/Dr. Laverson?
Friend/family
Walk/drive by
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Another Doctor
Other:
The above information is complete and correct. All information you provide will be strictly confidential except for possible use to inform others about the potential result of the procedure.
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