Client Intake Form (Prepaid)

Have questions or ready to book? We’re here to help you achieve your aesthetic goals with expertly delivered clinical treatments.

Step 1 of 2

Treatment

Referred By

Full Name

Address

State

Zip Code

Date of Birth

Phone Number

Mobile Number

Emergency Contact Name

Emergency Contact Mobile Number

Your data is encrypted and handled with absolute medical discretion.

About Image Med Spa

Image Membership

Your glow,
every month.

$99 / month

Thoughtful, consistent care designed to keep your skin looking and feeling its best.

Member-exclusive care

Make professional self-care part of your routine with your choice of one select treatment:

10% off non-laser treatments 50% off one new-member treatment*

$198 due today, then $99 per month after the 90-day trial period. *Laser treatments excluded. Terms may apply.