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Elim Consultation Form
Full name
*
Date picker
*
Birthday
*
Day
Month
Year
Do you suffer from Psoriasis, Eczema or Dermatitis in the area to be treated?
*
Yes
No
Do you have any known allergies or Diabetes?
*
No
Yes
Are you currently taking roaccutane or any other medication?
*
No
Yes
Are your feet affected by any to the following listed conditions?
*
Dry Skin
Cracked Heels
Callus Build up
Foot Odour
Itchiness
Thickened Nails
Overgrown Cuticles
Discoloured Nails
Skin Fungus
Nail Fungus
Blisters
Bleeding Heels
Corns
Verrucae
What are your main foot concerns and expectations?
*
How do you care for your feet at home?
*
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