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Home
New Clients
About Us
Training Center
Contact Us
Esthetician Services
Custom Facials
Micro Dermabrasion
Micro Needling
PRX DermPerfexion
HydraFacials
Brows, Liner & Lashes
Shaping Tinting or Restoring Color
Lash Enhancement
Wake Up With Make Up
Wrinkle Relaxers
Daxxify
Jeuveau
Xeomin
Botox
Lip & Facial Fillers
Versa
RHA
Radiesse
Bellafill
Clinical Services
Instalift
Plasma IQ
Intracel
Laser Treatments
Fractional CO2
Skincare
Reviews
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Name
*
First
Last
Email
*
Phone
*
Is Your Phone an Iphone?
*
Yes
No
Birthday
*
Who Can We Thank For Referring You To Our Office?
*
Emergency Contact; *Include Name and Phone Number*
*
Home Address; Include City, State and Zip
*
Regarding Your Health:
*
Pregnant or Breast Feeding
History of Cold Sores
Latex Allergy
Reaction to numbing agent ie; Lidocaine
NOT including Cleanings; Dental work in the past 4 weeks
Routinely take Aspirin, Ibuprofen or Fish Oil
I Take Medication You Should Be Aware Of
I Have Multiple Allergies And/or An Unusual Health History
Recent Sinus Infection Or Chronic Sinus Issues
I Am Taking Antibiotics Or Have Recently Taken Antibiotics
I Am In Good Health
Tox Treatments - Wrinkle Relaxers: Botox, Dysport, Xeomin, Jeuveau & Longest Lasting - Daxxify
*
I Get Treatments 1 Or 2 Times A Year
I Get Treatments 3 Or 4 Times A Year
It Has Been Longer Than 1 Year
Haven't Had - Would Like Information Only
Haven't Had - Would Like A Treatment
Have Had - Would Like A Treatment
Not Interested
Fillers For Smile Lines, Add Volume To Lips, Cheeks, Hands Etc
*
Had Within The Past 1-6 Months
Had Within The Past 6-12 Months
Longer than 1 Year
Would Like Information Only
Would like information AND a treatment
Not interested
Skincare Products - I Primarily Use
*
Medical Grade Products
Drug & Department Store Products
Complimentary Skincare Samples Are Provided
*
Normal
Normal to Dry
Normal to Oily
Acne Prone
Sensitive
What Best Describes Your Daily Skincare Routine
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Diligent routine AM + PM
Diligent routine AM
Diligent routine PM
Not diligent with a routine
It Is Important We Allow Adequate Time For Appointments
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Consult Only - No Treatment: 45 min
Consult + Tox Treatment: 1 hour
Consult + Filler Treatment: 1.25 hours
I would like something not listed
I have an appointment for Permanent Cosmetics
Existing Client - updating information
When You Look In The Mirror Does Your Eye Go To A Certain Area? If So, What Bothers You Most?
*
We Do Our Best To Accommodate Preferences. What Are Your Best Days? Morning Or Afternoon?
*
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