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Forms

MIRAGE Salon & MedSpa

Patient Information and Medical History

Patient Information

Sex
Male
Female

SECTION 1: MEDICAL HISTORY

Have you had any of the following you currently have or have had in the past?
Are you currently under the care of a physician?
Yes
No
Please check any of the following that apply to you; past or present.
Any other medical illnesses?
Yes
No
Are you currently pregnant?
Yes
No
Allergies?
Yes
No
Type of Treatment Requested

SECTION 2: CONSENT

By signing below, I attest the above information to be true, knowing my provider relies on this information to provide safe and effective treatment.

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