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What anti-aging goals do you have for your skin? Please select all that apply.(Required)
What other goals do you have for your skin? Select all that apply.(Required)
Please select how dry/oily your skin is.(Required)
How sensitive is your skin?(Required)
Are you currently using tretinoin, retin-A, or other retinol product?(Required)
What strength tretinoin or retin-A are you using?(Required)
Do you have any of the following skin conditions? Please select all that apply.(Required)
Are you allergic or sensitive to any of the following topical products? Please select all that apply.
Which of the following do you use. Please select all that apply.(Required)
Is there anything else you want to tell your doctor?(Required)
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Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.
Please attest to the following confirming that all information you have provided to us is true and complete. If you do not agree, you may not submit this form. Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.(Required)
What is your preferred language for communication with our medical team? (¿Cuál es su idioma preferido para comunicarse con nuestro equipo médico?)(Required)
Address
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