Medical Laser & Skin Rejuvenation Center

P 250.478.2336 Toll Free 1.888.578.2336

Dr. Daniel Milkovich MD
Dr. Kent Banks MD

 

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Client Intake Form

CONTACT INFORMATION
*ALL CONTACT INFORMATION FIELDS ARE MANDATORY*
(mm) (yyyy)
WHERE DID YOU HEAR ABOUT US? (please check all that apply)
TV ad
Internet Search
Radio
MagazinesBoulevard Magazine
Douglas Magazine
Encore Magazine
Western Living Magazine
West Shore Magazine
SNAP Magazine
Homes & Living Magazine
YAM Magazine
OtherYellow Pages
West Shore Go2Guide
Beautiful You
Healthy Living
Women In Business
Greatlife Passport
Business Examiner
Event/Trade Show
    
Refer a Friend/Current MDE Client
    
MD Esthetics Staff Member
    
MY SKIN CONCERNS ARE (please check all that apply)
Fine Lines, WrinklesDeflated, Sagging Cheeks
Love HandlesBrown Spots, Age Spots
Lip DefinitionBags Under Eyes, Dark Circles
Redness, RosaceaLip Size
FrecklesFacial Veins, Visible Vessels
Deep Lines, Facial FoldsFrown Lines, Crow's Feet
Acne, Acne ScarringSun Protection
Downturned SmileSkin Texture, Enlarged Pores
Dry SkinNeck Bands, Waddle
Unwanted HairOily Skin
Hand Spots, WrinklesLeg Veins
MelasmaExcess Sweating
Traumatic or Surgical ScarsTired Eyes, Droopy Brows
Stretch MarksShape of My Nose
Double Chin
Do you have any allergies? Include allergies to medications, skin care products, adhesives, and latex:
Other Skin Concerns:
CANCELLATION POLICY
Please note that MD Esthetics requires 24 hour notice to cancel or re-schedule an appointment for a procedure. Should you be unable to provide 24 hour notice, a $50 re-booking fee will be applied to your next payment.
I accept
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