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L Aesthetics

Patient Info

Name(Required)

Questions

eg latex, Peanuts, Shelfish
Are you currently on or have taken the following medications or have taken the following in the last 6 months?(Required)
Are currently experiencing?(Required)
Have you had any of the following in the last 6 months?(Required)
E.g. Glycolic/lactic acid, vit A/C, Benzoyl peroxide.

Patient Consent


Name(Required)
Clear Signature