Full Name: Jeron Pronger
Date of Birth: 1981-12-20
Email Address: firstname.lastname@example.org
Emergency Contact: Jayme Pronger 763-300-7644
Medical History : Back problems, Headaches / Migraines, –
Additional Details :
Have you been under the care of a dermatologist within the past year? No, –
Are you taking any medications or dietary supplements? Yes, – daily vitamin
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, – botox
Do you wear contact lenses? No, –
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? ,
Body Concerns:Stress, Aches / Pains, –
What is your current facial care routine?
Facial concerns: , –
What is your current body care routine?
Name : Jeron Pronger
Signature : https://www.mrvlspa.com/wp-content/uploads/ocswcf_signatures/signature-704-1651522629.png
Enter Date : 2022-05-02