• In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential.

  • PERSONAL INFORMATION

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  • SKIN HISTORY

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  • MEDICAL HISTORY

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  • MEDICATIONS

  • ACKNOWLEDGEMENT

  • I do understand that there is a 24-hour cancellation notice. If I fail to notify Limitless Medspa within that time frame, will be charged $100 for Physician appointments and $50 for non-physician appointments. 

  • I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. 

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  • Should be Empty: