Name *
Name
Date of Birth *
Date of Birth
Phone *
Phone
Emergency Contact Phone *
Emergency Contact Phone
Are you taking any medication? *
Are you pregnant or breastfeeding? *
Are you or have you been on Accutane in the last 6 months? *
Have you ever had any skin treatments before? *
Are you allergic to any food or medications? *
Do you have any health problems? *

* By clicking "submit", I certify under penalty of perjury that the above information is true and correct to the best of my knowledge. I understand that is in my best interest to provide this information for medical emergency and privacy protection.  I acknowledge that the above information will not be used in a manner that is contrary to HIPAA privacy laws.