(201) 321-8020

Eatontown NJ United States 07724

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CAROL DIMITRIADES

Alternative & Holistic Health Service · Professional Service

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SCHEDULE A SESSION

OR CONTACT CAROL FOR MORE INFORMATION

Eatontown NJ United States 07724

(201) 321-8020

Name *

Child's Name & age (if applicable)

Email *

City/Town *

Phone No.

Current Allergies/Health Issue

Please Include SKIN TEST results and RAST numbers from allergy testing within the last year (include Total IgE level for RAST test

Have you (or child) been prescribed and EpiPen?

Have you (or child) had an anaphylactic reaction? If yes, please explain (include dates)

Additional Details Related to Current Health Issues