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11
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1
Are you a new or existing patient?
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I am a new patient.
I am a returning patient.
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2
What is your name?
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First Name
Last Name
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3
When is your birthday?
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4
What is your email address?
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example@example.com
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5
What is the best phone number to reach you?
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Please enter a valid phone number.
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6
Please select your preference:
*
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In-Office Consultation
Virtual Consultation
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7
Have you ever received treatment from a medical spa? If yes, please specify treatments in the "Other" section.
*
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Yes
No
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8
Which treatment(s) are you interested in?
*
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Please select all that apply.
Facial Balancing
Graceful Aging
Botox & Fillers
Bridal Consultation
Skin Consultation & Lasers
Lips
Laser Hair Removal
Brazilian Butt Lift
Vampire O-Shot (The Orgasm Shot)
Fat Melting
Hair Restoration
Botox Party
IV Vitamin Therapy
Other
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9
Please provide us with days/times that work best for your schedule:
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10
Tell us more about what you are looking for:
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11
If time permits, would you like to receive a treatment on the day of your first consultation? If so, which treatment? :
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