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Home
About
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Medical info
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Contact

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Home
About
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Medical info
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Are you taking any kind of medication topical or oral?

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Medical story

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do you have any surgery?

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Do you have metal implants in any part of your body?

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Do you have a pacemaker?

Yes No

Have you received botulinum toxin?

Yes No

Date of last one

Have you received dermal fillers?

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Date

What kind?

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Skincare Body Treatments Advance Treatments Antiaging Consultation

Covid-19 Health Declaration

Name

Last Name

Email

My body temperature is lower than 98.6°F / 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat, shortness of breath.

I haven´t been in close contact with a covid-19 patient in the last 14 days.

Initials

Date

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

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(832)387-5467
jsaesthetic.antiaging@gmail.com
16300 Katy Freeway suite 130 Houston Texas 77094

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