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General Consultation Form
First Name
Surname
Street Address
Street Address Line 2
City
Postal / Zip code
Email address
Phone
GP Surgery
GP Name
GP Phone
Do you take any prescribed medication?*
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No
Do you take any prescribed medication?*
*
Yes
No
Do you take any prescribed medication?*
*
Yes
No
If yes, add details here
If yes, add details here
Alignments?
*
Yes
No
If yes, add details here
Have you ever had an allergic reaction?
*
Yes
No
If yes, add details here
Skin analysis
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Normal
Dry
Oily
Sensitive
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