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Gift
TREAT Your
Loved Ones
Medical Consultation Form
Please fill out the following form
in order to procede with the treatment
First Name
Last Name
Date of Birth
*
required
Email
Phone
Street Address
Street Address Line 2
City
Postal / Zip code
Country
Which treatment (s) are you having?
*
Required
Anti Wrinkle Injection
Dermal Filler
Profhilo
Hair Laser Removal
Hifu
Fat Freeze
Vasculase
Do you have any of these medical condition? :
*
Required
Pacemaker
Diabetes
Heart Condition
High Blood Pressure
Epilepsy
Pregnancy
Breast Feeding
Alergies
Under medications
Muscular Disoder
Recent Operation (less than 4 months)
None Above
If you answered 'yes' to any condition above, please give more details. Also, if you are under any medications, please list it below.
Have you had this treatment before?
*
No
Yes
If the answer is 'Yes' did you experimented any kind of reaction or allergy?
*
Yes
No
I declare that the info I’ve provided is accurate & complete
Initials
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