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New Patient History (Form 2/4)

Full payment is due at the time services are rendered. A fee of $250 will be charged for any missed, rescheduled, or cancelled appointments with less than 48 business hours notice. A non-refundable deposit of $1000 is required to schedule major procedures.

Prior Cosmetic Procedures
Do you have a history of oral cold sores? Required
Do you have a history of HIV? Required
Do you have a history of Hepatitis? Required
Do you have a history of skin cancer? Required
Do you suffer from hay fever/eczema/allergic rhinitis? Required
Do you suffer from any medical condition affected by flashing or flickering lights? Required
Have you had any dental work or vaccines administered in the last two weeks? Required
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