Personal Information

How did you here about us?

Conditions you are currently experienceing today (please select all that apply)

Which aroma(s) do you prefer? (please select all that apply)

Esthetics Information

What type of skin do you have?

What areas of concern do you have regarding you skin?

Have you been under the care of a dermatologist within the past year?

Yes No

If yes, please explain

Have you ever had an allergic reaction to any of the following?

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products?

Yes No

Have you received Botox, Restylane, or Collagen injections in the last 6 months?

Yes No

If yes please describe:

Please take a moment to read the following information:

By checking this box and signing below, you agree to the following I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history.

Type Your Full Name Below

Skin care form

Customer Service

location & hours