General Consultation Form

General Consultation Form

Please complete this form for expedited consultations and recommendations.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender
E-mail (you will receive email reminders for appointments)*
Mobile Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Allergies:*
Medications and Supplements (topical, oral, over the counter)*
Occupation *
General level of stress*

1 - little to no stress23 - somewhat stressed45 - high stress
Please upload a photo of the area you are looking to addres.
For example...
Full face or body part (arms, legs, abdomen).

No makeup please. Natural light if possible.

This is optional but will help us address your concerns quicker.
Upload photo here

Browse Files

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How would you describe your skin over the last 30 days?*

OilyDryCombinationSensitiveAcne-promeRosacea
Prone to cold sores?*

YesNoUnsure
Do you smoke?*

YesNo
Are you pregnant or breastfeeding?*

YesNoUnsure
How would you rate the overall quality of your skin? 1= Bad, 10= Fantastic!*
1, 2, 3, 4, 5, 6, 7, 8, 9, 10
Please mark all products you are currently using:*

CleanserBar Soap on your faceTonerSerumScrubMaskEye CreamExfoliantsMoisturizerSunscreenSelf TannerOther
What are your main skin concerns? (select all that apply)*

AcneAcne ScarringAge SpotsBlackheads/ Clogged PoresBody AcneDry/ Flaky SkinExcessive OilFine Lines/ WrinklesFrequent BreakoutsLarge PoresMelasmaRednessRosaceaRough/ Uneven Skin TextureSkin Laxity (loose skin)Sun DamageOther
Are there any treatments or products you are interested in?*

Unsure- would like recommendationsSkin CareFacialDermaplaneEnzyme PeelChemical PeelOxygen TreatmentHydraFacialMicroneedlingMicroneedling with Skin TighteningIPL LaserLaser Hair RemovalLaser Skin RejuvenationLash/ Brow TintLash Lift (curling up of natural lash)Eyelash ExtensionsMicroblading Semi-Permanent TattooingPermanent Eyebrow Shading (powder brows)Permanent Eyeliner or Eyelash EnhancementPermanent Lip BlushingBotox/ NeurotoxinDermal FillersOther
Additional Comments
Best Day(s) and Time(s) for a consultation*

MorningsAfternoonsEvenings (after 3)MondayTuesdayWednesdayThursdayFridaySaturday (available 1 saturday per month)Other
Preferred Method of Contact*

Phone CallTextEmailFacebookOther
Please note: it may take up to 3 business days for a reply.
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