Name:*

Full Legal Name:*

Gender / Pronouns

Phone Number:*

Email Address:*

Address:*

Apartment, suite or unit number

City*

Date Of Birth:*

Do you follow a restricted diet? (Such as Vegan, gluten free, etc)*

If you do, please specify:

Please list all allergies:*

What Treatments/Services are you interested in?*

Questions that you would like to ask?

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.*

I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.*

I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history.*

I understand the treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.*

Retainers &/or deposits are non-refundable/non-transferrable.*

Cancellations should be made prior to 48 hrs to avoid additional fees up to full amount. *

Referred by or how did you find us?*