Dermal Filler Patient History & Consent
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Name *
Date of birth *
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/
MM
/
AAAA
Phone number *
Email address *
Have you previously received dermal filler?
 *
If so, when was the last time you had filler?
DD
/
MM
/
AAAA
Type of dermal fillers received?
Do you have a history of anaphylactic shock? 
 *
Do you have any allergies? *
Do you take any of the following medications or supplements?
 *
Obligatorio
Please list any other medications or supplements you take regularly 
 *
Do you have or have you had any of the following medical conditions?
 *
Obligatorio
Describe any other medical history below, as long as an explanation of any of the conditions you marked with "Yes."
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