M.D. Laser Studio HUNTERSVILLE New Patient Health History Form

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*THIS IS FOR NEW PATIENTS WHO HAVE NOT BEEN TREATED AT MDLS Huntersville (formally "DE NOVO AESTHETICS" BEFORE. If you are an established patient, please complete the Established Patient Health Form.*

Please complete this Health History Form to the best of your ability. Thank you!

Email *

Legal Name *

Preferred Name

Date of Birth *

YYYY

Age *

Which most closely describes your gender? *

Male

Female

Prefer not to say

Other:

Race (choose all that apply) *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White or Caucasian

Hispanic or Latino/a

Middle Eastern or North African

Other:

Required

Marital Status *

Married

Single

Divorced

Widowed

Prefer not to say

Other:

Street address, city, state, zip code *

Best number to contact you *

May we text you appointment reminders and messages? If yes, you will need to Opt-In to Communications by checking the box in the "Communication Opt-In" Section of this form. *

Yes

May we leave a message (voicemail or text message) at the phone number provided?

If yes, you will need to Opt-In to Communications by checking the box in the "Communication Opt-In" Section of this form.

Yes

Other:

Communication Opt-In

By providing my phone number, I consent to receive SMS text messages from De Novo Aesthetics for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out. [https://denovoaesthetics.com/privacy-policy] [https://denovoaesthetics.com/terms-and-conditions]

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May we email you necessary forms and treatment plans? *

Yes

Best email address for forms, treatment plans, etc. *

Would you like to receive email and/or text notifications of specials and promotions? *

Yes

Occupation *

Hobbies

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