4. Apartment / Suite (optional)
9. Emergency Contact Name & Phone Number *
10. Were you referred by someone?
11. What is your occupation? *
12. Are you currently pregnant? *
13. Any existing or recent illness? *
14. Any recent hospitalization or surgery? *
15. Please list the names of any medications you are taking: *
16. Are you taking any of the following medications? *
17. Do you have any of the following allergies or sensitivities? *
18. Please indicate any other allergies: *
19. Have you had any aesthetic procedures in the treatment area within the last 6 months? *
20. Which of the following conditions apply to you? (check all that apply)? *
21. Do you have medical insurance? *
The appointment time you have chosen is the fee you will be charged.
The ways you can reschedule or cancel your appointment are:
1. Online through scheduling system or ("View My Appointments")
2. By telephone (time-stamped) at 902-478-7393 up to 48 hours before your appointment.
After this time passes your credit card is automatically charged or an invoice issued. Same applies to no-show appointments. Appointments must be paid before the commencement of your next treatment. Forms or requests (other than this one) are not monitored (e.g. e-mails or messages sent through Facebook or other social media sites will not be accepted as a cancellation request). Thank you.