If you're a new patient, please fill this out:

First Name

Last Name

Date of birth

Address

City

State

Postal code

Phone *

Email *

Emergency Contact Name

Emergency Contact Relation

Emergency Contact Phone

Summarize your beauty/physical goals or concerns:

Gender

Summarize anything specific you'd like us to discuss

Possible Referrals

A FEE OF $35.00 WILL BE CHARGED FOR RETURNED CHECKS OR SAME-DAY CANCELLATIONS OR NO-SHOWS.

Please be sure to provide us 24-hour notice.

You're risking a $50.00 charge, but in some cases, we may be able to apply that to your next visit as a courtesy.

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