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Email
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First name
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Last name
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Address
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DOB
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Please answer the following health consern
Diabetes
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Heart concern
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Hepatitis
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Blood disorder
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Communicable disease
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Allergies
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Pregnent
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Breast feeding
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Allergy to latex
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Currently undergoing radiation or chemo
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Currently taking acne medication
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Yes
No
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Glaucoma
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Yes
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Eye infection
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Yes
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Contact lenses
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Botox
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Blepharitis
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