First-Time Patients: Do not complete this form. Please call us at 212-334-3774 to schedule your first appointment. Return Patients: Please complete the fields below.

First Name *

Last Name *

Date of Birth * (mm/dd/yyyy)

Phone *

Email

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 Laser appointments, your credit card on file will be charged a deposit of $100. For Ultherapy appointments, your credit card on file will be charged a deposit of $300.

 BBL (Broadband Light) for Freckles, Brown Spots Botox / Xeomin Chemical Peel: Glycolic / Jessners / Refinity / Salicylic Clear+Brilliant Laser Earlobe Repair Surgery Excel V Laser for Eyes, Facial Veins, Brown Spots, Bruises Filler: Juvederm / Radiesse / Belotero / Volbella / Restylane Hybrid Laser (Clear+Brilliant / Profractional) Kybella for Submental Fullness, aka Double Chin Laser Hair Removal Profractional Laser Sclerotherapy for Leg Veins truSculpt Body Contouring Ultherapy V-Beam Laser for Redness, Rosacea, Capillaries, Scars Vi-Peel Other:

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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