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Contact me by...
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Phone
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Best time to call...
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Considering this for...
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Less than 1 month
Between 1 and 6 months
More than 6 months
When?
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I'd like to setup a consultation soon
I'd consider coming in for a consultation after receiving more information
I'd really like to get this done in the next 4 months
I'm likely to have this procedure in the next year
Any other information you'd like to ask?
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Technician
Financing
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I do not need financing
I may want to find financing
I've already applied for financing
Medical History
Are you currently being treated for a condition not listed? Please specify
Are you currently taking any physician prescribed medications? If yes, please specify.
Do you have any implants, tattoos or permanent makeup in the area to be treated? If yes, please specify.
Do you have any allergies? If yes, please specify.
Have you ever been treated by an endocrinologist? If yes, please specify.
Have you used or are you currently using Retin-A? If yes, please specify
What products are you currently using on your skin?
Have you ever or are you currently using Accutane? If yes, please specify.
Have you had a major surgery performed in the last 3 months? If yes, please specify.
Do you urinate/leak when you sneeze, run or jump?
Have you ever had any laser treatments or chemical peels in the last 6 months? If yes, please specify.
For women, when was your last menstrual cycle?
Are you currently pregnant? If so, when is your due date?
Date
I understand Minneapolis Skin Clinic requests a minimum 24 hour advance notice when rescheduling or cancelling an appointment to avoid a cancellation fee. No shows, no calls, or appointment cancelled without 24 hours notice will be subject to a $50 missed appointment fee.
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If you are human, leave this field blank.