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GP Address:

Do you have any of the following?
DiabetesPsoriasisSunburnPregnancyEpilepsy

Do you have any allergies?
YesNo
If yes, please specify

Do you have any of the following skin conditions?
AcneEczemaRosaceaSkin CancerOther
If other, please specify

Do you have any ongoing medical treatments?
YesNo
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Are you taking any medication?
YesNo
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Do you have any dietary restrictions?
YesNo
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Are you currently pregnant or breastfeeding?
YesNo

Do you have any specific concerns for your appointment?

I confirm that the above information is accurate and up-to-date.