Contact Us

Call: 810-623-1884
Email: [email protected]
Address: 111 N Street St. 
City, State Zip

Hours

Monday: 12p - 7p
Tuesday: 10a - 4p
Wednesday: 12p - 7p
Thursday: 10a - 4p
Friday: 10a - 5p
Saturday: By Appointment Only
Sunday: By Appointment Only

Phone
Phone

5841 Whitmore Lake Road, Suite C
Brighton, MI, 48116
United States

(810) 623-1884

New Client Form

New Client Form

Contact Info
Name *
Name
Date of Birth
Date of Birth
Address
Address
Emergency Contact Phone Number
Emergency Contact Phone Number
Your Skin
Do you use Retin A, Renova, Adapalene Hydroxyl Acid, Differen, Glycolic or Lactic Acid, AHAs, Salicylic Acid, or Retinol/vitamin A derivative products?
Have you used any of these products in the past 3 months?
Have you used an acne medicine orally or topically?
Do you form thick or raised scars from cuts or burns?
Do you have hyperpigmentation (dark spots) or hypopigmentation (light spots) after physical trauma?
Have you been exposed to the sun or tanning beds in the past 48 hours?
How frequently are you exposed to the sun or tanning beds?
Have you ever had an adverse reaction to a skin care product?
PREVIOUS TREATMENTS
Facials?
Any complications?
Microdermabrasion?
Any complications?
Chemical Peels?
Any complications?
Botox/Fillers?
Any complications?
Waxing
Any complications?
Spray Tan?
Any complications?
MEDICAL HISTORY
Have you been under the care of a physician or dermatologist in the past year?
Any recent surgery, including plastic surgery?
Have you been diagnosed with skin cancer?
Have you had any of these health concerns past or present?
Do you follow a restricted diet?
Do you wear contact lenses?
Do you have a pacemaker?
Have you ever experience claustrophobia?
Do you suffer from sinus problems?
Have you ever had an allergic reaction to any of the following:
FEMALE CLIENTS ONLY
Are you taking oral or subcutaneous contraceptives?
Any recent changes to or from your contraceptive treatment?
Are you pregnant, trying to become pregnant or lactating?
Are you experience perimenopause or menopause?
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