New Patient Form - Mpls Anti-Aging & Skin

Call Us


Golden Valley
Maple Grove

New Patient Form


New Patient

New Patient Form

* If you are a new patient please continue to fill out the NEW PATIENT INTAKE FORM below.
To ensure the effectiveness and safety of your treatment and to assist us in recommending the best program for your skin, please complete this confidential questionnaire.
Primary Phone Type
Secondary Phone Type
What Service/Services are you considering?
Are you interested in non-invasive body contouring?

Medical History *

Are you currently being treated for a condition not listed?
Are you currently taking any physician prescribed medications?
Do you have any implants, tattoos or permanent makeup in the area to be treated?
Do you have any allergies?
Have you ever been treated by an endocrinologist?
Have you used or are you currently using Retin-A?
Are you currently using products on your skin?
Have you ever or are you currently using Accutane?
Have you had a major surgery performed in the last 3 months?
Have you ever had a chemical peel?
Have you ever had any laser treatments on the area(s) to be treated in the last 6 months?
Are you currently pregnant?
I understand that Minneapolis Anti-Aging & Skin Clinic requests a minimum of 24 hour advance notice for reschedule or cancellation of appointments to avoid a cancellation fee. No shows, no calls, or appointment cancelled without 24 hour notice will be subject to a $50 missed appointment fee.


Find your results today!



Our Locations

Golden Valley


4825 Olson Memorial Hwy #201
Golden Valley, MN

Office Hours

M - Th 9am-7pm | F 8am-5pm | Sat (by appt) 8am-4pm

write a review  

Maple Grove


7748 Main St. N
Maple Grove, MN

Office Hours

M & T 9am-7pm | W Closed | Th 9am-7pm | F 8am-5pm | Sat (by appt) 8am-4pm
write a review