* = Required Information
In case of emergency: Name of friend or relative we can contact
Fine Lines & Wrinkles Acne/scars
Smile Lines or Deep Wrinkles Sun Damage or Age Spots
Vein Complications Loose Skin
Unwanted or Excess Hair Thinning lips
Dull or Lifeless Skin
Please answer the following question to the best of your knowledge. This information will be used in order to provide you with a better quality of care.
Please indicate any previous surgeries or past hospitalizations:
Asthma Heart Disease
Seizures Thyroid Disease
Cancer Hypertension
Stroke Ulcer
Diabetes Pneumonia
Tuberculosis Venereal Disease
Family History:
Always burns, never tans Always Burns, sometimes tans
Sometimes burns or tans Always Tans
Hispanic, Asian, Mediterranean Black
Yes   

Sarah Edwards, PA-C    Mubina Siddiqui, NP    Dr. Parsa    Amanda Paranda, PA-C   
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