Impotentie brengt een constant ongemak met zich mee, net als fysieke en psychologische problemen in uw leven cialis kopen terwijl generieke medicijnen al bewezen en geperfectioneerd zijn

Please introduce yourself.
Name: ________________________________________________________________________ Today’s Date: ________________
Birth Date: ______ /______ /______ Age: _______ qMale qFemale E-mail: __________________________________ Home Phone: ( ) ________________________________ Cell Phone: ( ) ____________________________________ Home Address: ______________________________________________________________________________________________ City: ______________________________________ State: ______________________________ Zip: ________________________ Occupation: _______________________________________ Business Phone: ( ) _________________________________ Spouse’s Name: _________________________________________________________ In case of emergency, please contact:
Name: __________________________________________________________________________________________________________ Phone: ( ) __________________________________ Cell Phone: ( ) ______________________________________ May we share your medical information with this person? qYes qNo Please list anyone else we can share your medical information with: __________________________________________________ ____________________________________________________________________________________________________________ Where did you hear about Ideal Image®?
qFriend or Family Member, Name: ____________________________________________________________________________ qPhysician Referred, Name: __________________________________________________________________________________ qRadio qTV qBillboard qMagazine/Newspaper qInternet qLocal Event qOther __________________________ How do you preferred to be contacted? qPhone qE-mail qText Message Would you like to receive special offers and promotions from Ideal Image® via e-mail? What are your three favorite radio stations? _____________________________________________________________________ What are your three favorite web sites? ________________________________________________________________________ We do not sell any customer information to any third party. Neither do we provide any individually identifiable customer information to any third party except as follows: in response to sub-poenas, court orders or legal process, in order to finalize a payment for services requested and agreed to with your personal Ideal Image® consultant. This information may be shared with your financial institution or credit card issuer as indicated.
GIF - Version 063010 | 2010 Ideal Image Development, Inc.
Name ____________________ Chart# ____________________ Please tell us about yourself.
Have you ever had laser treatments or Electrolysis? Procedures/Areas treated: _____________________________________ Any complications? _____________________________ Please Circle The Areas You Need Treated On The Diagram Below
In order to better establish your skin type, please tell us your race/ethnicity: ___________________________________
Please Check The Box That Best Describes Your Skin Type:
Never tans, always burns (extremely fair skin, blonde hair, blue/green eyes) Occasionally tans, usually burns (fair skin, sandy/brown hair, green/brown eyes) qSkin Type III Often tans, sometimes burns (medium skin, brown hair, brown eyes) qSkin Type IV Always tans, never burns (olive skin, brown/black hair, dark brown/black eyes) qSkin Type V Never burns (dark brown skin, black hair, black eyes) qSkin Type VI Never burns (black skin, black hair, black eyes) GIF - Version 063010 | 2010 Ideal Image Development, Inc.
Name ____________________ Chart# ____________________ Medical history
How would you describe your general health? Have you had a major illness or been hospitalized within the last 5 years? qYes qNo Please describe: _____________________________________________________________________________________________ Are you currently using any medications? (Topical, Ingestible or Injectable) qYes qNo List all medications and conditions: _____________________________________________________________________________ Have you taken Accutane in the last 6 months? qYes qNo Are you using Rogaine, Propecia, Minoxidil? If yes, please list: ___________________________________ Do you have any tattoos and/or permanent makeup? qYes qNo If yes, where? ______________________________ qYes qNo Please list: _____________________________________________ Are you taking Aspirin, Advil, Motrin or any other over the counter medications? qYes qNo List: ________________________________________________________________________________________________________ Are you taking any herbal or vitamin supplements? qYes qNo List: ____________________________________________ Do you use tobacco? qYes qNo Type: __________________________________________________________________ Do you consume more than two alcoholic beverages per day? qYes qNo Have you ever had any of the following:
What type: qBasal Cell qDysplastic Nevus qSquamous Cell qMelanoma If yes, when: _______________________________________ Where on the body: _________________________ Was it treated and how? ________________________________________________________________________ GIF - Version 063010 | 2010 Ideal Image Development, Inc.
Name ____________________ Chart# ____________________ Have you ever had any of the following:
qLiver Disease/Hepatitis (A, B, or C) qKeloid Scarring qVasculitis with/without skin involvement qHormone/Thyroid Disorder qAbnormal Blood Pressure (high or low?) qConnective Tissue Disorders qAnemia qAllergy to Lidocaine or other "caines" qBleeding Disorder Please describe or explain any of the above: ________________________________________________________________________________________ Have you ever had any surgical procedures? Please describe: _____________________________________________________________________________________________ Have you ever had any of the following treatments: qChemical Peel qGlycolic Peel qMicrodermabrasion qCosmetic Surgery qOther: ___________________________________________ What skin care products are you using? (Cleanser, Moisturizer, etc.) _________________________________________________ ____________________________________________________________________________________________________________________ Do you use or have you ever used any of the following products? qRetin A qAHA qHydroquinone qOther: _________________________ Any reactions? ____________________________________________________________ Is there any other information about your health that we should know? ______________________________________________ ___________________________________________________________________________________________________________________ WOMEN ONLY: Are you pregnant? qYes qNo
Expected Delivery Date: __________ /__________ / ___________ Are you trying to become pregnant? qYes qNo Are you taking oral contraceptives? qYes qNo Patient Signature: ___________________________________________________ Date: ________ /________ / ________
Person responsible for account (If under 18)
Parent/Legal Guardian Signature: _______________________________________ Date: ________ /________ / ________
Confirmed for treament by: __________________________________________________ Date: ________ /________ / ________ Treatment Provider/Medical Director Signature GIF - Version 063010 | 2010 Ideal Image Development, Inc.


Onium Chemicals B.V., The Netherlands T.: +31(0)6 20171394; F.: +31(0)847233093; Mail : Productlist API based on product in alphabetical For products detailed specifications or MSDS, please contact us by email to PRODUCT NAME APPLICATION 7689-03-4 (+)-Camptothecin 200815-49-2 (R,R)-Formoterol-L-(+)-Tartrate 826

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