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Beauty : Skin Care

PDF: Application And Consultation Form Acne Skin Care Treatment

Download 7 times Source: www.dermacarecares.com // Topic: Beauty : Skin Care File Size: 117.86 kb // Total of Page: 5 Page(s) Last download by ElysiumBeauty Last download on: 5 months ago Share this info: Sample of page (click to enlarge) Short Desciption: 16) Which of the following best describes your skin type? ? Very oily skin, large pores. ? Oily skin ... Dermacare Laser and Skin Care Clinics ... Content Inside: Application And Consultation Form Acne Skin Care Treatment Date: _____________20___ Patients Last Name: _______________________First Name: ______________________ Date Of Birth: ________________________ Age: ________ Gender: Female Male Parent or Legal Guardians Name: _____________________________________________ Street Address: ______________________________________________________ Apt./Suite #: ______________________________________________________ City: ______________________________ State: _____ Zip Code: ____________ Home Phone: (_____)_______________ Work Phone: (_____)________________ Cell Phone: (_____)_______________ Email Address: _______________________________________________________ "Bigs" Name: __________________________ Phone: (_____)________________ In case of an emergency, does the "Big" listed above have authorization to pick up your c hild? Yes No Emergency Contact: ______________________ Phone: (_____)________________ In case of an emergency, does the emergency contact listed above have authorization to pick up your child? Yes No *REQUIRED FOR SKIN ANALYSIS & TREATMENT* Patients Ethnicity: _________________________________________________________________ Biological Mothers Ethnicity:_________________________________________________________ Biological Fathers Ethnicity: ________________________________________________________ Are you tan? ____________ Do you tan artificially? Tanning Bed Spray on Tan When was the last time you had a significant amount of sun exposure? ___________________ DermacareCARES Application Patients Last Name: ______________________ First Name:____________________ DermacareCARES Application And