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ProMax Lipo Consultation Form
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Surname
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Names
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Address
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DOB
MM
/
DD
/
YYYY
Telephone number
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E-mail address
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Doctor's name and address
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Ethnic origin
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Occupation
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What are you trying to target mainly from this treatment?
Lax skin
Lines & wrinkles
Cellulite
Localised fat
Other:
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Body areas
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