Client Quote / Secure Upload (PIPEDA/HIPAA)
Submit your treatment request or area of concern to weinject Medical Review Team
Clien Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Area of Concern or Desired Correction
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What was the date of the treatment that you have concerns about?
*
-
Month
-
Day
Year
Date
In order for our Medical Review Team to help, please describe the product, brand or device that was used for your treatment if you can recall
*
If you are comfortable type in the Clinic, Medical Spa, Doctor and/or Nurse who performed your treatment
*
Please submit as many clear photos as possible, in order for our Medical Review Team to make an informed recommendation for your circumstance(s)
*
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We have a monthly promotional offering which is a massively reduced rate treatment offering! We only send out one email per month. Would you like to receive this email (Some clients are on the sneak peak list and they receive as sneak peak of the promotion one month in advance!)
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YES! Add me to both the Monthly Promotion & the Sneak Peak List!
YES! Send me the Monthly Promotion
Add me to the Sneak Peak List!
No, thank you!
We have a Last Minute Client promotional offering which is a greater massively reduced rate treatment offering! We only send out one email prior to practicum (class) once we have to fill up the space or have a last minute cancellation. Would you like to receive this email mailing list?
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Yes! Add me to the Last Minute Client mailing list!
No, thank you!
Please feel free to elaborate about your concern(s)
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