NEW CLIENTS Please fill out the form below so we can help you book your first appointment! Name * First Name Last Name Phone * (###) ### #### Email * Preferred Contact Method * Phone Email Availability – 1st Choice * MM DD YYYY Availability – 2nd Choice MM DD YYYY Preferred Time * Hour Minute Second AM PM Are you currently pregnant or breastfeeding? * Yes No Have you ever used Accutane? * Yes No If Yes, when was the last time you used it? What are you looking to improve about your skin? * Detailed skin history from the last 2 years (including treatments received and skincare products you are using. * Do you tan? * Yes No Do you use SPF? * Yes No Do you have any known allergies? * Yes No If Yes, please list below. Are you allergic to latex? * Yes No What is your ethnic background? * [Choose One] White Black Asian Amerindian/Alaska native native Hawaiian/Pacific Islander Mixed ethnicity Do you get injectibles? * Botox/Filler Yes No If Yes, when was your last treatment? Is there anything else you would like me to know? Thank you!
