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Health History Intake Form

Do you have any of the following conditions? Check all that apply.
Are you currently under the care of a physician or dermatologist?
Any surgeries within the last 6 months?
Any dermal injections/fillers within the last 6 months
Are you using any products that contain Retin –A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription or over the counter skin product?
Have you used any of these products in the past 3 months?
Have you ever had any allergic reaction to any skin products

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