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Name *

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Address *

Address 1

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Date of Birth *

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I am interested in: (Please check all that apply)

Botox

Fillers

Rosacea

Acne Treatments

Fine Lines/Wrinkles

Sun Damage

Cellulite Reduction

Skin Tightening

Fat Reduction

Tattoo Removal

Skin Care Advice/Products

Microdermabrasion

Facial/Leg Vein Treatments

Hair Removal

Vaginal Rejuvenation

Others

When you sunbathe, how does your skin respond? *

Always burn, never tan

Usually burn, tan with difficulty

Sometimes burn,tan about average

Almost never burn, tan very easily

Rarely burn, tan easily

Never burn, always tan

Medical History

check appropriate box next to any condition for which you have ever been treated

Acne

Arthritis

Autoimmune Disorder

Blood Disorder

Cancer (or Radiation Therapy)

Diabetes/Diabetic neuropathy

Herpes (or Cold Sores)

Hirutism

Vitiligo

Kidney Disease

Melanoma

Port Wine Stain

Psoriasis

Pacemaker

Shingles

Skin Pimentation

Steroid or Hormonal Therapy

Hormonal Imbalances

Polycystic Ovarian syndrome

Keloid Scars/Other Scars

By clicking "Agree and Consent to Treatment" I am stating that all of the information on this form is accurate and complete.

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Agree and Consent to Treatment