First Name
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Last Name
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Email Address
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Phone Number
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Address
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City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
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What Service/Services are you considering?
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Injections (Botox, filler, Kybella, vitamins)
Lasers
Peels
Skin Care products
Hormone Therapy
Body Contouring
What Service/Services are you considering?
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.
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.