Krupa –

Full Name: Krupa
Date of Birth: 1996-04-22
Email Address:
Emergency Contact: Emily Olson
Medical History : Other, – NA
Additional Details :
Have you been under the care of a dermatologist within the past year? Yes, –
Are you taking any medications or dietary supplements? Yes, – Accutane
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? No, –
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? Yes,
Body Concerns:, –
What is your current facial care routine?

Facial concerns: , –
What is your current body care routine?

Name : Krupa patel
Signature :

Enter Date : 2022-05-08

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