Aesthetics Eligibility

1

Are you 25 years or older?* This field is required.

YESNO

2

Are you currently pregnant, breastfeeding, or planning pregnancy soon?* This field is required.

YESNO

3

Have you been diagnosed or suspect having a neurological disorder?* This field is required.

YESNO

4

Do you take blood thinners or Accutane or other strong acne meds?* This field is required.

YESNO

5

Have you been diagnosed with an eating disorder, body image disorder, psychosis, bipolar disorder, suicidal ideation?* This field is required.

YESNO

6

Do you currently have an infection, dehydration, or an uncontrolled or untreated illness?* This field is required.

YESNO

7

Do you understand that aesthetic procedures are not covered by insurance or Medicare and require your payment out of pocket?* This field is required.

YESNO

8

Congratulations! We'd love to learn more about you. To be contacted, please share your Name:* This field is required.

First Name

Middle Name

Last Name

9

...and Mobile Phone Number (Text Capable)* This field is required.

10

By the way, if you'd like to be updated on specials and new services, you may also share your Email Address. (We won't share it with others).

example@example.com