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Get Westwind Cosmetic & Laser Center New Client Medical & Aesthetic History Form

Er XI or newer, print, sign and bring with you to the office. Ask for a copy of the form for your records. Personal Information First Name: Birth Date: Last Name: Address: City: Home Phone: State: Cell Phone: Email Address: Date: Zip Code: Work Phone: Occupation: How did you hear about Westwind Cosmetic & Laser? What brings you to Westwind Cosmetic & Laser? What is you ethnic background? Medical History & Medical Conditions Past or Present Yes Do you have any chronic medical condi.

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