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New Patient Profile and Health History
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First Name *
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Middle Initial
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Street Address *
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City, State, Zip *
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Cell Phone
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Home Phone
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Email *
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Date of Birth
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Contact Phone
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Referring Provider
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Referring Provider Phone Number
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If under 18, person responsible for your account
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Pharmacy Name
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Pharmacy Phone
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How did you hear about us?
For Females: Are you currently or planning pregnancy / breastfeeding?
For Females: During pregnancy did you develop hyperpigmentation or masking?
Which of the following best describes your skin type?
Past Medical History (Please check all that apply)
Past Personal Skin History (Please check all that apply)
Please list previous hospitalizations / surgeries / serious illnesses (include year if known)
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Please list all medications (include prescription, OTC, vitamins, herbs, and supplements) and reason for taking
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Please list all medication allergies and reactions
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Do you have any of the following?
Latex Allergy?
Iodine Allergy?
Lidocaine Allergy?
Smoking Status
Reason for visit (Please check all that apply)
How have you previously treated the problem?
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