First Name *

Last Name *

Date of birth *

Gender in Birth *

Phone *

OK to contact you by phone calls/voicemail? *

Yes

No

OK to contact you by SMS? *

Yes

No

Email *

OK to contact you by Email? *

Yes

No

Occupation *

Marital Status *

Ethnicity *

We ask about ethnicity as part of our scientific approach to personalized care. Different ethnicities have unique genetic skin characteristics, which can affect how the skin responds to certain treatments and products. By understanding this, we can reduce the risk of complications like hyperpigmentation and ensure you receive the safest and most effective treatment.

Emergency Contact Name *

Relationship to You

Emergency Contact Phone *

What are your main concerns? *

Multi-select

Which treatments would you like to hear more about? *

Multi-select

Are you currently pregnant or trying to become pregnant? *

Yes

No

Are you currently breastfeeding? *

Yes

No

Do you have diabetes (Type 1, Type 2 or gestational)? *

Yes

No

Do you have a history of high blood pressure or heart problems? *

Yes

No

Do you have a personal history of any cancer? *

Yes

No

Do you currently have any kind of cancer? *

Yes

No

Do you have any autoimmune conditions? *

Yes

No

(examples: rheumatoid arthritis, psoriasis, lupus, etc.)

Do you have any blood or clotting issues, or take blood thinners? *

Yes

No

Do you have liver (hepatic) disease or hepatitis? *

Yes

No

Do you have kidney disease or kidney function problems? *

Yes

No

Do you have any neurologic conditions? *

Yes

No

(examples: seizures, stroke, multiple sclerosis, epilepsy, etc.)

Do you have HIV or AIDS? *

Yes

No

Do you have any mental health diagnoses we should be aware of? *

Yes

No

Do you have any abdominal issues? *

Yes

No

(examples: hernia, bariatric surgery, other major abdominal surgery)

Do you have any medical implants? *

Yes

No

Do you have any metal implants *

Yes

No

(examples: plates, screws, joint replacements, etc.)

Do you have a pacemaker? *

Yes

No

Do you have a history of cold-related conditions? *

Yes

No

(examples: Raynaud’s, cold urticaria/hives, cryoglobulinemia, etc.)

Do you have any numbness or loss of sensation in the areas you want treated? *

Yes

No

Are you currently experiencing any other illness or medical issue not mentioned above? *

Yes

No

Do you currently take any medications or supplements? *

Yes

No

Have you ever had a bad reaction or complication from cosmetic treatments? *

Yes

No

(injectables, laser, chemical peels, facials, devices, etc.)

Do you smoke or vape nicotine? *

Yes

No

On most days, do you drink at least ~2 liters (half a gallon) of water? *

Yes

No

Have you had any previous treatments on your FACE? *

Yes

No

(laser, peels, microneedling, RF, exosomes, etc.)

Have you had any previous treatments on your BODY? *

Yes

No

(liposuction, fat freezing, cavitation, RF, EMS, etc.)

Do you currently have any fillers or neuromodulators? *

Yes

No

(Botox, Xeomin, Jeuveau, etc.)

Date of Signature *