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MLS
Centre de médecine esthétique
23,bis rue de Constantinople
75008 Paris
Tel :01 40 08 05 05

NOM :…………………………………..…….. PRENOM :……………………….………………..

Tel :……………………………………………………………………………..……………………..

E.mail :…………………………………………………………………………….………………….

Date de naissance :………………………………………………….……………………………

Je soussigné Mme/Mr…………………………………………………………………..…………

Avoir pris connaissance du consentement éclairé.

Fait à Paris le…………………………………………………………………………………….

Lu et approuvé

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