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Laser business forms c.indd

Name: _________________________________________________ Date of Birth: ______________________________________ Address: ___________________________________________________________________________________________________ City ________________________________________________________________ State ________________ Zip: ____________ Email: _________________________________________________ Today’s Date: ______________________________________ Home Phone:____________________________________________ Business Phone:____________________________________ Cell # or Preferred Contact #: _______________________________ Is it important to be discrete?__________________________ How did you hear about us? ____________________________________________________________________________________ Describe the nature of your visit? ________________________________________________________________________________ ___________________________________________________________________________________________________________ What are your expectations?____________________________________________________________________________________ ___________________________________________________________________________________________________________ Please fill out any of the following that may apply:
Have you been on Accutane in the past 6 months?_______________ Include any other medications that make you photo sensitive (antibiotics): _______________________________________________ Have you taken doxycycline, minocin, minocycline, or vibramycin recently? When?_______________________________ ___________________________________________________________________________________________________________ List all medications you are currently taking (blood thinners, herbs, supplements, vitamins, aspirin etc.): _______________________ ___________________________________________________________________________________________________________ Have you ever had allergic reactions to: Food Latex Nickel Aspirin Lidocaine Hydrocortisone Hydroquinone/Bleaching Agents Other______________________________________ Are you currently under the care of a physician? If so, what for? _______________________________________________________ ___________________________________________________________________________________________________________ Any Allergies: _______________________________________________________________________________________________ ___________________________________________________________________________________________________________ Acne:
Do you have a history of breakouts? Yes No
If so, what is the frequency of your breakouts? Frequent Occasional Rarely
Do you experience cystic breakouts? Yes No
Do you have any scarring as a result from your acne? Yes No
Skin Background:
Skin Disease: ______________________________________ Lesions: _____________________________________________ Chronic Rash: ______________________________________ Melanoma: __________________________________________ Surgical Scars: _____________________________________ Psoriasis: ____________________________________________ Hairy Moles:_______________________________________ Are you currently under the care of a dermatologist? If so, for what? ____________________________________________________Have you had prolonged sun exposure (or tanning bed) in the past 3 days? Yes NoIf so, are you currently sunburned? Yes NoDo you use tanning beds? Yes NoAre you using chemical tanning solutions? Yes NoDo you use sunscreen on a regular basis? Yes NoHave you waxed, used depilatories, bleaches or other chemical processes? ________________________________________How much water do you normally consume daily? __________________________________________________________________ Have you had Botox or Collagen injections in the past 6 months? Yes No If yes, and less then 3 months, approximate dates and location. ________________________________________________________Do you use topical ointments? Retin-A Glycolic Lactic Acid Hydroquinone Other: ___________________________What type of skin care products are you using? _____________________________________________________________________ ___________________________________________________________________________________________________________ Check other services of interest:
Laser Hair Removal (list different areas) ________________________________________________________________________ Laser Vein Removal Non-ablative LaserFACIAL Pigmented Lesions or Brown Spot Removal Other: ________________ I certify that the above medical history information is accurate and correct:
Patient Signature: ________________________________________ Date:_____________________________________________ DR/Tech Signature:_______________________________________ Date:_____________________________________________

Source: http://www.lrhrc.com/assets/patient_medical_history.pdf

Notice pension adalat-1 for website

Controller of Communication Accounts NO/CCA/MPTC/Admn/XI1th PensionAdalat/ Dated:-13/12/2013 To 1. The CGMT, BSNL, MP CIrcle,Bhopal. 2. The CGMT, Telecom Factory, Ridge Road, Jabalpur 3. The CGMT, T&D Circle, Jabalpur 4. The CGMT, BRBRAIT, Jabalpur. Subject: XII th Pension Adalat to be held on 29-01-2014 This office is conducting the XIIth "Pension Adalat" on 29-01-201

Microsoft powerpoint - 20090826 cover students' report [互換モード]

Quantitative evaluation of drug transport and metabolism in the body Research Department of Genetic, Evolution and Environment, University College London (UCL), London, United Kingdom Professor Yuichi Sugiyama Associate Professor Hiroyuki Kusuhara Department of Molecular Pharmacokinetics, Graduate School of Pharmaceutical Sciences, The University of Tokyo Abstract

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