By signing below, you are agreeing to the following:

• A $259 booking retainer is required prior to booking
• The booking retainer covers your skin scan, consultation and custom treatment performed during the initial visit.
• The retainer is only applicable to the date and time originally booked.
• Purchase of the required homecare routine is mandatory to begin treatment. This is part of the physician-directed protocol.
• No refunds or appointment transfers will be issued for any reason.
A proper signature is required. Any incomplete signatures will result in the form being deleted.

Signature *

Clear

Your Name *

Email *

Phone *

DOB *

Message

Gender *

Are you 18 years or older? *

We do not currently accept teen clients unless referred by existing client.

If not 18, type full name, DOB, and relationship of the adult filling out this form

How did you hear about us? *

Select which treatment you're interested in. All first time treatment options are $259 + homecare. *

Select the first option if you're unsure. Homecare will be purchased at your first appointment.

Which treatments are you interested in learning more about at your consultation? *

Explain any pertinent skin history: *

What is your budget for your homecare investment? *

Homecare typically starts around $200+. We will do our best to stay within your selected budget and skin goals.

Saturday-Monday: CLOSED

Tuesday- Fri day: 9:00am - 7:00pm

Enter your preferred date, day of the week, and timeframe *

You may also indicate "no preference". List more than one preference, if possible.

Type "I agree" here if you agree to pay the booking retainer fee of $259

This is required. No retainer fee collected will result in the form being deleted.

Request passcode