New Patient Forms Connecticut

New Patient Forms

Click here to download the registration forms and have them completed prior to your visit.

To complete an electronic copy of the registration forms using Adobe Acrobat Reader, download them here.

Please contact us at 860-404-6133 if you have any questions.

Routine Cosmetic Consultation with doctor $150; applied towards procedures over $1000
Problem Cosmetic Consultation with doctor $250-$500; NOT applied towards any procedures
Skincare or Makeup Consultation with esthetician $75; will apply to product purchases
Skin Clearance with doctor for prescription products & Skincare Consultation with esthetician. $150 physician consultation ONLY no charge for consultation with esthetician

First Name*
Last Name*
Phone
Email*

Please list us as a safe sender. If you do not see a response within 48-hours please check your spam filter.
Procedure of Interest*
Please choose "other" if you don't see your option here.
Interested in a Virtual Consultation?*
Message
HIPAA Disclaimer
“This e-mail message and any documents attached to it are confidential and may contain information that is protected from disclosure by various federal and state laws, including the HIPAA privacy rule (45 C.F.R., Part 164). This information is intended to be used solely by the entity or individual to whom this message is addressed. If you are not the intended recipient, be advised that any use, dissemination, forwarding, printing, or copying of this message without the sender's written permission is strictly prohibited and may be unlawful. Accordingly, if you have received this message in error, please notify the sender immediately by return e-mail or call (860) 409-1515, and then delete this message. Please be advised that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. If you prefer to exchange information in a more secure format, we suggest doing so by telephone”.
Comments
This field is for validation purposes and should be left unchanged.