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The Skin Clinic
Intake form
Help us serve you better
Name
*
Phone number
Email address
*
What is your age range?
Select
18-24
25-34
35-44
45-54
55 and older
What services are you interested in?
Please select at least one option.
Facials
Chemical Peels
Microdermabrasion
Laser Treatments
Skin Consultations
Fat disolver
Do you have any skin concerns?
Please select at least one option.
Acne
Wrinkles
Hyperpigmentation
Dry Skin
Oily Skin
Sensitivity
Have you had any prior skin treatments?
Please select at least one option.
Facials
Botox
Fillers
Laser Treatments
Chemical Peels
None
What is your skin type?
Select
Normal
Dry
Oily
Combination
Sensitive
Are you currently taking any medications for your skin?
Do you have any allergies we should be aware of?
Which service or services are you interested in?
Please select at least one option.
Signature Medical Facial treatments
PLATELET- RICH PLASMA
PLASMA FIBROBLAST-SKIN TIGHTENING
Acne professional facial
Microneedling Facial (DERMAPEN)
Alopecia-Hair loss growth
Initial consultation for $150
Follow-up consultation for $100
Signature Medical facial
Additional questions or comments
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