Questionnaire For Cosmetic Procedures
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Name
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First
Last
Email
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Phone
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Please Narrow Your Requirements According to Concerns or Procedures
Search Treatment By:
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Concern(s)
Multiple Concern(s)
Procedure(s)
Concern
Select Your Concern
Abdominal Pannus
Acid Reflux
Acne
Acne Medication
Acne Scars
Age Spots
Anti-Aging
Anxiety And Depression
Anxiousness
Back Fat
Baggie Eyelids
Baggy Arms
Baggy Eyelids
Bladder Problems
Bloating
Body Contouring
Brain Fog
Bruise Easily
Build Muscle / Tone
Cardiovascular Disease
Celiac Disease
Cellulite
Chronic Kidney Disease
Cleaner For Oily Skin, Comedones
Cleanser
Cleanser For Acne
Cllulite
Colon Cancer
Collagen Foramation
Constipation/Diarrhea
Crow's Feet (Wrinkles On Side Of Eyes)
Decline In Drive Or Interest
Decreased Bone Mass
Depressed Scars
Dermatosis Papulosis Nigra
Diabetes
Difficulities With Memory
Dilated Pores
Distention
Discoloration
Discomfort During Intercourse
Double Chin
Droopy Brow
Droopy Eyelids
Dry Skin On The Body
Dry Skin On The Face
Dull Appearing Skin
Eczema
Elevated BMI
Elevated Hga1C
Elevated Blood Sugar
Elevated Cholesterol
Elevated Lipids
Enlarged Abdominal Area
Enlarged Breast Size
Enlarged Flanks
Enlarged Hips
Enlarged Nose (Rhinophyma)
Enlarged Pores
Enlarged Upper Back
Enlarged Upper Thigh
Erectile Changes
Excessive Sweating (Hyperhidrosis)(Arm Pits And Feet)
Face Contouring
Facial Contouring
Facial Fullness/Drooping
Facial Rejuvenation
Fatigue
Fatigue, Skin Issues, Hair Loss, Joint Pain, And Brain Fog
Feeling Cold All The Time, Having Cold Hand And Feet
Filler For Eyelids
Fine Lines
Fine Lines And Wrinkles
Flatten Cheeks
Food Sensitives
Forehead Lines
Frown Lines
Gas
Hair Loss Or Thinning
Hair Thining
Headaches Or Migranes
High Cholesterol
Hollow Temples
Hot Flashes Or Flushes
Hyperhidrosis (Excessive Sweating)
Hyperpigmentation
Hypertropic Scars
ILL Defined Lip Line
Increased Body Fat (Especially In The Waist Area)
Inflammatory Conditions (Inflammatory Bowel Disease
Infrequent Or Abscent Ejaculations
Irritability
Irritable Bowel Syndrome
Jaw Clenching (Tmj)
Jawline Contouring
Joint Or Muscular Pain
Jouls
Jowls
Lack Of Sexual Sensation During Intercourse
Leakage With Laughing, Jumping Or Coughing, Etc
Lines Around Mouth
Lip Shape And Size
Loss Of Muscle Mass
Loss Of Tone
Low Mood
Low Sex Drive
Low Sexual Desire, Activity, Orgasm
Make-Up
Melasma
Mild Redness
Moisturizer For The Body
Moisturizer For The Face
Mood Changes
Nasolabial Folds (Loss Of Collagen)
Neck Bands
Neck Wrinkles
Neck/ Chest Wrinkles
Night Sweats
Obese
Oily Skin
Oral Commisures (Corner Of Mouth)
Painful Intercourse
Preventative Anti-Aging
Psoriasis
Preventioin For Sun Damage
Recurrent Boils & Abcesses (Hydradenitis Supprativa
Recurrent Vaginal Bacterial Infections
Recurrent Yeast Infections
Red Spots (Cherry Angiomas)
Redness (Rosacea)
Reduced Sexual Desire
Removal Of Dead Skin
Sagging Skin Above Knees
Saggy Buttocks
Saggy Eyelids
Saggy Knees
Saggy Skin
Scar Revision
Short Neck
Side Handles
Skin Care Advice
Skin Care Products
Skin Crepiness
Skin Rashes
Skin Resurfacing And Anti-Aging
Skin Texture
Sleep Problems
Small Areas Of Unwanted Fat
Small Blood Vessels (Telangiectasia)
Spider Veins
Stress
Stretch Marks
Sun Damage
Surgical Scars
Texture Changes
Thick Thighs
Thin/Uneven Lips
Tired Eyes
Tone
Trouble Sleeping
Under Eyelid
Undersiable Of Girth Or Length Of Penis
Unhappy With Appearance Of Vagina
Unwanted Hair (Any Location)
Urinary Incontinence
Vaginal Dryness
Vaginal Laxity
Vertical Lip Lines (Smoker's Lines)
Volumne Loss And Aging
Volumne Loss And Aging (Cheeks, Nasolabial Fold, Marionett Lines, Hands)
Volumne Loss On Back Of Hands
Weight Gain
Weight Gain Despite Exercise
Wrinkles
Wrinkles On Muscle Movement
Procedures To Help With Concern
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Individual Procedure
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Concern(s)
*
Abdominal Pannus
Acid Reflux
Acne
Acne Medication
Acne Scars
Age Spots
Anti-Aging
Anxiety And Depression
Anxiousness
Back Fat
Baggie Eyelids
Baggy Arms
Baggy Eyelids
Bladder Problems
Bloating
Body Contouring
Brain Fog
Bruise Easily
Build Muscle / Tone
Cardiovascular Disease
Celiac Disease
Cellulite
Chronic Kidney Disease
Cleaner For Oily Skin, Comedones
Cleanser
Cleanser For Acne
Cllulite
Colon Cancer
Collagen Foramation
Constipation/Diarrhea
Crow's Feet (Wrinkles On Side Of Eyes)
Decline In Drive Or Interest
Decreased Bone Mass
Depressed Scars
Dermatosis Papulosis Nigra
Diabetes
Difficulities With Memory
Dilated Pores
Distention
Discoloration
Discomfort During Intercourse
Double Chin
Droopy Brow
Droopy Eyelids
Dry Skin On The Body
Dry Skin On The Face
Dull Appearing Skin
Eczema
Elevated BMI
Elevated Hga1C
Elevated Blood Sugar
Elevated Cholesterol
Elevated Lipids
Enlarged Abdominal Area
Enlarged Breast Size
Enlarged Flanks
Enlarged Hips
Enlarged Nose (Rhinophyma)
Enlarged Pores
Enlarged Upper Back
Enlarged Upper Thigh
Erectile Changes
Excessive Sweating (Hyperhidrosis)(Arm Pits And Feet)
Face Contouring
Facial Contouring
Facial Fullness/Drooping
Facial Rejuvenation
Fatigue
Fatigue, Skin Issues, Hair Loss, Joint Pain, And Brain Fog
Feeling Cold All The Time, Having Cold Hand And Feet
Filler For Eyelids
Fine Lines
Fine Lines And Wrinkles
Flatten Cheeks
Food Sensitives
Forehead Lines
Frown Lines
Gas
Hair Loss Or Thinning
Hair Thining
Headaches Or Migranes
High Cholesterol
Hollow Temples
Hot Flashes Or Flushes
Hyperhidrosis (Excessive Sweating)
Hyperpigmentation
Hypertropic Scars
ILL Defined Lip Line
Increased Body Fat (Especially In The Waist Area)
Inflammatory Conditions (Inflammatory Bowel Disease
Infrequent Or Abscent Ejaculations
Irritability
Irritable Bowel Syndrome
Jaw Clenching (Tmj)
Jawline Contouring
Joint Or Muscular Pain
Jouls
Jowls
Lack Of Sexual Sensation During Intercourse
Leakage With Laughing, Jumping Or Coughing, Etc
Lines Around Mouth
Lip Shape And Size
Loss Of Muscle Mass
Loss Of Tone
Low Mood
Low Sex Drive
Low Sexual Desire, Activity, Orgasm
Make-Up
Melasma
Mild Redness
Moisturizer For The Body
Moisturizer For The Face
Mood Changes
Nasolabial Folds (Loss Of Collagen)
Neck Bands
Neck Wrinkles
Neck/ Chest Wrinkles
Night Sweats
Obese
Oily Skin
Oral Commisures (Corner Of Mouth)
Painful Intercourse
Preventative Anti-Aging
Psoriasis
Preventioin For Sun Damage
Recurrent Boils & Abcesses (Hydradenitis Supprativa
Recurrent Vaginal Bacterial Infections
Recurrent Yeast Infections
Red Spots (Cherry Angiomas)
Redness (Rosacea)
Reduced Sexual Desire
Removal Of Dead Skin
Sagging Skin Above Knees
Saggy Buttocks
Saggy Eyelids
Saggy Knees
Saggy Skin
Scar Revision
Short Neck
Side Handles
Skin Care Advice
Skin Care Products
Skin Crepiness
Skin Rashes
Skin Resurfacing And Anti-Aging
Skin Texture
Sleep Problems
Small Areas Of Unwanted Fat
Small Blood Vessels (Telangiectasia)
Spider Veins
Stress
Stretch Marks
Sun Damage
Surgical Scars
Texture Changes
Thick Thighs
Thin/Uneven Lips
Tired Eyes
Tone
Trouble Sleeping
Under Eyelid
Undersiable Of Girth Or Length Of Penis
Unhappy With Appearance Of Vagina
Unwanted Hair (Any Location)
Urinary Incontinence
Vaginal Dryness
Vaginal Laxity
Vertical Lip Lines (Smoker's Lines)
Volumne Loss And Aging
Volumne Loss And Aging (Cheeks, Nasolabial Fold, Marionett Lines, Hands)
Volumne Loss On Back Of Hands
Weight Gain
Weight Gain Despite Exercise
Wrinkles
Wrinkles On Muscle Movement
Procedures
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Chemical Peels
Facials
Microdermabrasion
Laser Hair Removal
Intense Pulse Light (IPL)
Laser Genesis
Vascular Laser
Vascular Laser
Sclerotherapy
PEARRL Resurfacing Laser
Physique
Morpheus 8/Morpheus 8 Body
Botox®
Xeomin®
Diaxxify®
Juverderm®
Volumna®
Radiesse®
RHA 1®
RHA 2®
RHA 3®
RHA 4®
Sculptra®
PDO Threading
Liposuction with Facetite/Bodytite
Electrocautery
Surgery
Hormone imbalance
Weight management
GI Health
Supplements
GU
GRx Rejuvanater Cleanser
PRP
PRF
Exosomes
Female health
Area Of Interest
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Select any if applicable
Select Area
Face / Neck / Head
Upper Body
Lower Body
Multiple Areas
When Would You Like to Be Seen:
Timings: Wednesday 7am to 3pm | Friday 7am to 11pm
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7:30 AM
8:00 AM
8:30 AM
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9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
Time
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7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
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