Cosmetic Consultation Client Form

Cosmetic consultations are not covered by the BC Medical Service Plan. $75 is charged for cosmetic consultations and this fee can be applied to any treatment or service (not product) if done within 30 days of consultation. There are no refunds for consultation fees.

If you choose the PDF option, print and complete the form at home and bring it with you to your appointment. Or scan your completed form and email it to us at before you visit the clinic.

Please use this simple and secure online form which is signed electronically and sent directly to us immediately upon completion.

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Personal History

Brown or grey patches on skin

Rough scaly patches on skin

List Previous Aesthetic Procedures

Reason(s) for Requested Consultation. Where Can We Help?

Tell Us About Your Current Skincare Routine

I hereby certify that the above information is true and correct as to the best of my knowledge.

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