First-Time Patients: Do not complete the form below. Please call us at 212-334-3774 to schedule your first appointment and then fill out the demographic form here. Return Patients: Please complete the fields below.

First Name *

Last Name *

Date of Birth * (mm/dd/yyyy)

Phone *


Insurance Type and Member/Subscriber ID

Who would you like to see? *

If this is a medical visit, what is your appointment for?
Please be as specific as possible. For example you can say: Mole Check, Skin Cancer Screening, Acne, Rash, Nail Issue, Cortisone Injection, Hair Loss, Mole Removal Surgery, etc.

If this is a cosmetic visit, what is your appointment for?
Check all that apply. If you aren't sure, check "other" and provide a description of what you are looking for. For most appointments, your credit card on file will be charged a deposit of $100-$1000, depending on the treatment.

BBL (Broadband Light) for Freckles, Brown SpotsBotox / Xeomin / DysportChemical Peel: AHA / BHA / Jessners / RefinityClear+Brilliant LaserEarlobe Repair SurgeryEMSculpt Body Contouring - NEW!Excel V Laser for Eyes, Facial Veins, Brown Spots, BruisesFiller: Juvederm / Radiesse / Volbella / RestylaneHybrid Laser (Clear+Brilliant / Profractional)Infrared Glow with Alllumera and Light StimulationKybella for Submental Fullness, aka Double ChinLaser Hair RemovalMicroneedling with PRPProfractional LaserSclerotherapy for Leg VeinstruSculpt Body ContouringUltherapyV-Beam Laser for Redness, Rosacea, Capillaries, ScarsVi-PeelOther:

Please offer at least three dates and times (time ranges are good!) that work for you and we will email back with a confirmation or additional options.
Note that some laser appointments require you to arrive up to an hour before your appointment time for numbing.

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