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About the Spa
Our Services
IV Vitamin Bar
Botox / Xeomin
Microneedle
Ketamine
Memberships / Specials
Forms
Which forms do I need?
IV Vitamin Bar or Injections
Botox / Xeomin or Microneedle
Ketamine
5 free units of Botox
Memberships / Specials
$50 visa gift card with first treatment
Book Now
5 free units of Botox
Memberships / Specials
$50 visa gift card with first treatment
Rebel
Med Spa
Book
Now
About the Spa
Our Services
IV Vitamin Bar
Botox / Xeomin
Microneedle
Ketamine
Memberships / Specials
Forms
Which forms do I need?
IV Vitamin Bar or Injections
Botox / Xeomin or Microneedle
Ketamine
Menu
Pricing
Services
Call/Text
Rebel
Med Spa
Book
Now
About the Spa
Our Services
IV Vitamin Bar
Botox / Xeomin
Microneedle
Ketamine
Memberships / Specials
Forms
Which forms do I need?
IV Vitamin Bar or Injections
Botox / Xeomin or Microneedle
Ketamine
Menu
Pricing
Services
Call/Text
Menu
801-808-1647
Pricing
Services
Call/Text
CALL/TEXT 801-808-1647
Medical History
IV Vitamin Bar or Injections
Full Name
*
Date of Birth
*
Phone Number
*
Are you currently pregnant or trying to become pregnant?
*
List of Known Allergies
Medical History
Smoking
Alcohol
Illegal Drugs
Heart Condition
High Blood Pressure
Chest Pain
Stroke
Heart Attack
Kidney Condition
Blood Clot / DVT
Device Implant / Pacemaker
Lung Condition / Asthma
Cancer
Difficulty Swallowing
Vascular Problems
Neuropathy
Unexplained Weight Loss
Double Vision
Bladder Problems
Arthritis
Osteoporosis
PTSD
Anxiety / Depression
Seizures
Dizziness / Fainting
Head Injury
Chronic Pain
Nausea
Current Fracture / Infection
Diabetes
HIV / AIDS
Hepatitis
List any medical conditions not mentioned previously
List Current Medications
List All Previous Surgeries
Are you currently ill? List symptoms.
Please explain any MAJOR surgeries or serious medical conditions?
?
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Date
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