4. Please Indicate which, if any, cosmetic treatments you have done in the past. Be sure to include date

4. Please Indicate which, if any, cosmetic treatments you have done in the past. Be sure to include date of the last treatment and your level of satisfaction with results. J Microdermabrasion J Skin tightening laser (list which type) Chemical peels (please list which type) J Botox J Dermal fillers 3 Photorejuvenating laser (list which type) J IPL 3 Laser hair removal Cosmetic surgery J Body contouring/fat reduction treatment (list which type) 5. Please list your full AM & PM skincare - regimen. PM. 7. Please indicate who referred you to our practice. 9. Please list any allergies to medications. 6. Please provide the name and contact information of your primary physician. Name: Phone number: n 8. Please list any medications, prescriptions or supplements you are currently taking. 10. Are you pregnant, planning on becoming pregnant or breast feeding? 6. Please provide current pharmacy information including address, phone number and fax number.' EvS.57tn Street d Eroacway. 212 - :came, Fa. (21; ass sass VITA\CAL-Ti-A OT AVG:. 1004C I prior-) e FAX • This information is raquirrid rota •-iMiirr•WICY OrMaintiont EFTA00314098