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Medical Questionnaire

Please fill out the following form to help us understand your physical condition- For Fat Freezing /Emvibe Treatments

PLEASE TICK IF YOU HAVE ANY OF THE FOLLOWING OR IF IT APPLIES TO YOU: --- High Blood Pressure / Diabetes / Heart Issues / Pregnant / Skin Sensitivity to cold temperatures / Do you have any skin conditions sensitivity that may affect you from doing a treatment / Abdominal Hernias / Cryoglobulinemia cold agglutinin disease /paroxysmal cold hemoglobinuria
Are you currently suffering from a medical condition, illness, or injury?

Thanks for submitting!

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