NEW PATIENT FORM

If this is done already, great! You're all set!

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:

Please be sure to provide us 24-hour notice of any changes or cancellations.

We stay on time.

You can count on us! Teamwork!

A fee of $35 will be charged for bounced payments, last-minute cancellations, or no-shows.

We may be able to apply that to your next visit as a courtesy.

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