Please answer the following questions so that we have a better understanding of your general health and lifestyle. This will aid your Skin Care Professional in a more accurate analysis and/or the possible contributing factors to progress and improvement of your skin. Thank You!

Medical History (Please select all that apply)

Nutritional Regime (Please select all that apply)


  • Please be on time. If you are late, a shortened session will be charged at the full rate.
  • We request payment in full at the time of your visit. We accept cash, Visa, MasterCard and personal checks.
  • We require 24-hour notice for all cancelations or postponements: otherwise you will be charged a $50 fee. As a courtesy, we give clients a telephone reminder a day or two before appointment.
  • All series must be used within 1 year. No refunds are given after the 1-year expiration date.
  • I understand that the therapist does not diagnose illness, disease, or any other physical or mental disorder. The therapist does not prescribe medical treatment or pharmaceuticals. It has been explained to me that this treatment is not a cure or substitute for a medical examination, treatment, or diagnosis. It is recommended that I see a physician for any ailments that I might have. All information that I provided is correct to the best of my knowledge. If any health issues arise, I agree to inform my therapist.