DPC Waitlist Sign-up

For those who want to become a new client.

Please complete this form. You will be notified once there is an opening for you!

Full Name

First NameLast Name

Phone Number

Please enter a valid phone numberFormat: (000) 000-0000.

E-mail

example@example.com

Birth Date

MonthDayYear

How did you hear about Skin by Alyssa Lee? Google, Instagram, Friend, Family, Social Media? (please state the name of who referred you if so)

Please list all specific skin care concerns and goals (Include what your skin is like on a regular basis, what you're looking to improve or achieve by coming to Alyssa Lee, important information of skin history, prior treatments received, etc.). The more information, the better, so we can come up with an effective plan for you!

Specific skin service(s) you are interested in receiving: (All services include a consultation and skin analysis prior to beginning a service) (For questions regarding information on services please refer to main website. For questions regarding pricing on services please contact us)

What makes you want to come to Alyssa Lee specifically for your care?

Are you looking to make skincare services/treatments a monthly/regular thing?

Preferred Date/Time/Day of week that you are hoping for (or say no preference if none):

Is there a special occasion or certain reason you are eager to get in as soon as possible/before a certain date?

You will be contacted by Alyssa Lee to schedule if your appointment request has been accepted. Please email alyssaleeskin@outlook.com for any additional questions or concerns.

Please read carefully and check all:

New Client Waitlist/Appointment Request Form