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COVID Questionnaire
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Step
1
of 6
Your main cosmetic concerns:
*
Explain the details of your concerns
*
Your cosmetic goals:
*
What have you had done to tackle your concerns:
Date of Birth:
Past cosmetic procedures
Next
Your Name
*
First
Last
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Your Phone Number:
Your Email
*
Next
Any medical history?
Diabetes
Hypertension
Heart Disease
Any other Past Medical History
*
List of current medications
*
Allergies
*
Next
History of wound(s)
*
Treatments
*
Antibiotics
Hyperbaric Oxygen
Surgery
Other:
Next
Send profile picture and the area of your concern
*
Click or drag files to this area to upload.
You can upload up to 4 files.
You can submit maximum of 3-4 pictures of yours.
Next
Choose the type of visit:
*
First Visit - $ 125.00
Follow Up - $ 75.00
Total
$ 0.00
Please enter your credit card number and name on the card
*
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Card
Name on Card
Date / Time
Date
Time
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