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Interested in getting a luxury facial?

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Health Declaration

Please fill out so we can give you the best facial experience. Appointments are in NYC courtesy of Biologique Recherché.

This is a perk. Thanks for being a monthly members who has signed up in our supportive care model.

For internal use only. We will never share your information.

First name

Last name

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Date of Dignosis

Have you had a diagnosis of cancer?

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Yes

Are you currently in treatment for cancer?

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Yes

Are you experiencing a different heath issue?

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If you answered yes to any question, please elaborate

Select any that apply to you:

Surgery

Lymphy Node Removal

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Hormone Therapy

Radiation

Recurrence

Metastasis

None of the above

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You Can Thrive! (917) 463-4267 • A Collective of Talented Practitioners & Locations • Main Office: 535 W 23rd. St, NY, New York, NY

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