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Rx. all rights reserved.
Complete the form below if you are not pregnant or breastfeeding, do not have a history of seizures or coagulation disorders, are not prone to keloid scarring or do not have a localized infection or skin cancer on area being treated.
Check to confirm that none of the above conditions apply
Scheduling your first appointment will be determined by availability as well as timing around the contra-indications below.
Do you use any oral medication supplements or topical cream that causes sensitivity?
Have you used Accutane within the last 3 months?
Have you had any Botox or filler injections within the last 5 days?
Have you received any facial peels (such as Chemical, Fraxel, CO2 laser) within the last four weeks?
Have you had any unprotected sun exposure including recent tanning or use of tanning beds or creams on the elect area to be treated?
Do you take any anticoagulation medication such as Aspirin, Plavix, Coumadin, and/or Vitamin E?
Do you take any steroids or Non-steroidal Anti-inflammatory oral or topical drugs?
Do you take any Anti-histamines?
I am 18 years or older
I am between 14 and 17 years old and will be accompanied by a parent/ guardian
Got referred by our customer? Enter their name here and they will receive a $25 gift card at their next visit.
And you can refer a friend to get $25 gift card too! It can be redeemed for any spa's services and products.
Thank you for taking the time to submit this form! A Ten Skin RX representative will call you within 24 hours to set up your first appointment after reviewing your Contra-Indications.
If you do not receive a call back within 24 hours please text your first name, last name and phone number to 204-814-3051. We look forward to speaking with you.