Date *
Name *
Phone *
DOB (date of birth) *
DOB (date of birth)
Mark all that apply to you. *
Check if you've had any of the following:
Please check if you are using the following:
How many caffeinated beverages do you drink daily? *
How much water do you drink daily? *
How many alcoholic beverages to you consume daily? *
Were you breast fed as a baby? *
Have you used antibiotics more than 10 times in your lifetime? *
Prior to retaining the services of Skin and Tonic, I understand that Skin and Tonic is not providing medical services or medical advice. Should I require medical advice or treatment, Skin and Tonic encourages me to consult with a licensed primary health care provider. Skin and Tonic does not diagnose, prescribe or treat symptom, defect, injury or disease but instead provides self-help information that clients can utilize to increase skin health and over all well being.