Patient Information & History

Bel Viso Medical Aesthetics, LLC

General Info & Medical History
The Art Of Cosmetic Aesthetics

General Information + Medical History
Name
Date of Birth

MonthDayYear
Date
Phone
Address
City
State
Zip
Email
example@example.com
Emergency Contact
Phone
Any known allergies
Referred By
What is the reason for this consultation
Have you ever been treated for this problem
When
If so were you satisfied with the results
Current medications vitamins supplements
| understand that all this is an elective treatment and that all sales are non-refundable or

exchangeable and this elective treatment is a final sale.
Patient Signature & Date

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Should be Empty:

Bel Viso Medical Aesthetics, LLC