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Skin Care Intake Form

Please fill out the following form to help me understand your needs.

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?
Please check all current conditions that apply to you:
Do you have a pacemaker?
1. You will receive 100% of your deposit if you cancel 48 hours (2 days) in advance. Please choose yes if you understand. *
2. Less than 2 day notice we will be unable to refund your deposit. If you need to reschedule, we will gladly offer an alternative date up to 1 month for your consideration. Please choose yes if you understand. *

Thanks for submitting!

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