Intake Form

We ask that all new clients complete this comprehensive and confidential intake form. The more information we get, the better we can assess your skin and customize your treatments. If you have any questions or are unsure of an answer just skip by that question and you can review it with your practitioner when you are at the clinic.

Personal Information

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We do not share contact info with any 3rd parties. Opting in to our newsletter means you'll receive approximately 12-15 emails from us per year with specials, prizes and information.

NOTE: Please be sure to check your junkmail if you have not received a response from us via email within 24hrs during business days.

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Client Expectations

Medical History

(Check all that apply)

UV / Sun Exposure

Treatment History

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Skin care

Lifestyle & Diet

Your Appointment at SKN

If you know the name of the Package or Monthly Special please type it here
We will do our best to accommodate your choice but if it's not available we will get back to you with an alternate choice.
We will do our best to accommodate your choice but if it's not available we will get back to you with an alternate choice.
(Anything you'd like add about your appointment time request)

Please Review & Agree

I have read and will follow to the best of my abilities any and all instructions. I will let my practitioner know if I start any new medications, skin care products, become pregnant or have undergone any treatments at other facilities that could possibly affect the outcome of my treatment program at SKN Holistic Rejuvenation Clinic:

I understand there is a minimum of 24 hours to cancel or re-schedule a weekday appointment and 48 hours for Saturday appointments and that there is a $25 late cancellation fee and a credit card will be required for re-booking no-show appointments.