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Forms

Please complete and submit the forms below before your date of service.

Liability Waiver

First Name

Last Name

Email

Date of Birth

Any environmental, food or medication allergies?

Any previous surgeries?

If there have been previous surgeries, were there any complications? Please explain.

Date of last surgery (if applicable)

Please specify anything we should know about you

I declare that the info I’ve provided is accurate & complete

I hereby acknowledge I have read the terms and agreement in the link below.View terms of use

Initials

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Emergency Contact Form

YOUR OWN DETAILS:

First Name

Last Name

Email

Phone

Address

YOUR EMERGENCY CONTACT DETAILS:

Contact First Name

Contact Last Name

This contact is my

Contact Phone Number

Contact Email

Physician

Physician phone number

Special Instructions

Thanks for submitting!
We’ll contact this person only in case of emergency.

Subscribe for Updates

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Tel: 305.632.1762

Bootchieslove@gmail.com

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