Full Name: Elizabeth Clemens
Date of Birth: 1986-07-22
Email Address: elizabethlclemens@gmail.com
Emergency Contact: Eddie Clemens
Medical History : Other, – Nothing
Additional Details :
Have you been under the care of a dermatologist within the past year? Yes, – General visit
Are you taking any medications or dietary supplements? No, –
Have you had any surgery in the last 12 months? No, –
Have you received Botox, Restylane, Collagen or any other injections in the last 6 months? Yes, – Forehead and crows feet
Do you wear contact lenses? Yes, –
Is there anything that may be important for us to know?
For ladies: Are you pregnant, planning a pregnancy, breastfeeding, using birth control or menstruating? Array
For ladies: Are you taking birth control pills? No,
Body Concerns:Stress, –
What is your current facial care routine?
Facial concerns: Oily Skin/ Excess Shine, Blackheads/Whiteheads, Dehydration, Redness, –
What is your current body care routine?
Name : Elizabeth Clemens
Signature : https://www.mrvlspa.com/wp-content/uploads/ocswcf_signatures/signature-704-1651756336.png
Enter Date : 2022-05-05
