Neuromodulator Interest form

Neuromodulator Interest form

Help me bring the right amount of product!!
Hello Tox Party peeps!

PLEASE READ THIS FULLY IF CONSIDERING GETTING ANY TREATMENT AT YOUR UPCOMING PARTY.

If you are planning to get a treatment at the party you MUST fill out this form. If you are considering getting a treatment it is HIGHLY RECOMMENDED that you fill out this form.

This form makes it so that I can bring the correct amount of product to the party and allows me to send you the intake forms to be filled out prior to the party. Parties can be super hectic, so I need your help in making sure it goes as smoothly as possible.

If you are a new client you will be receiving intake forms to the email you list. These need to be complete prior to your treatment. If you are an existing client, you likely won't receive forms unless we have updated anything.

If you do not fill out this form and decide to get a treatment, that's no problem, but you will likely be required to go last to ensure that those who did fill out the form get their tox of choice. If you do not fill out this form, we cannot guarantee we will have your treatment available.

We always do mini consults prior to your visit, but if you are looking for a full consult, please come into our clinic to discuss more detailed concerns! You can book online!

We offer VI Peels at parties. Please note, that with this peel, it is medium depth - it does sting a little, and you will likely have peeling. Peeling can range from just flaking to full sheet peeling. The worst of the peeling is usually on days 3-5, so definitely plan accordingly. Please come with a freshly cleansed face.

Feel free to also email me with any questions.

For more info on treatments/products: check out www.headandhearthealth.com and follow me on @headandheartks

Email: headandheartks@gmail.com

Phone: (785) 554-0157

Prices are subject to change.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What party are you attending*

Erin September Botox and BubblyOther
Are you in?

Yes!It's going to be a no for me, dawgMaaaybe
Do you have a neuromodulator of choice?

BotoxDysportNo clue, just want itDaxxify
What do you generally like or are you interested in having treated

Glabella (11's/frown lines)ForeheadCrows FeetLip flipTMJ for jaw clenching/grindingB12 shot for me!! (B12 shots are an IM injection that generally gives a nice energy boost and may help with weight loss)Other
If other, please explain:
If wanting a VI Peel, which one sounds the most enticing to meet your needs?

VI Original: great for a first time peel, rosacea, or sensitive skinVI Advanced: great if your main concerns are aging and wrinklesVI Purify: great for active acneVI Precision Plus: great for melasma and hyperpigmentationVI Purify & Precision Plus: great for acne, acne scarring, and hyperpigmentation
Are there any product lines you would like me to bring. Remember, if purchased at the party, you get 20% off!

Biojuve: great for a perfect summer glow and a great skin microbiomeHydrinity: super hydrating line with great hyaluronic acids and otherObagi: vitamin C serums, retinol, and tretinoinOmnilux LED treatment: contour face mask; neck and decolletage mask; clear face mask; under eye mini; spot treatment miniGlyMed+: CHAPSTICK (my number one), brightening serum, and moreColorscience (ALL THINGS SPF FOR SUMMER TIME!!)Revision skincare: pretty much a whole range of amazing products - my favs include the vitamin C, the neck cream, lip plumper, and eye serumEpicutis: Simple, clean ingredients including lipid serum (anti-inflammatory and soothing), arctigen brightening treatment, and the best oil cleanser in the land(Plated): Exosome serum and eye serum - the latest and greatest in trending regenerative skin careOther
If other - let me know what skin issues you are experiencing and I can try to bring products that target those concerns. Also, feel free to mention anything else here

Neuromodulator Interest form

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