Online BLT Consultation

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Patient Name
Date of Birth
Online Treatment Agreement
Patient consent to download medical history?
Do you have any condition that may render you incapable of making sound medical decisions?
Do you have an allergy to a particular medication?
Do you have any of these conditions?
Do you currently take any of the following medications?
Do you currently take any other medications, including over-the-counter drugs?
When was your last in-person doctor visit?
Which best describes your skin type?
Please select conditions that apply to you.
Do you experience any of the following cardiovascular symptoms?
Have you or a family member ever had:
Treatment Warning and Precaution
Patient Assertation
Prescription will be sent to, 8950 SW 74th Court, Suite 101, Miami, FL 33156. Ph: 786-803-8947.