Website consultation

1
What type of visit would you like to schedule?
New consultation/treatment
A follow up visit or part of a previously scheduled package
Other
2
What service or treatment are you scheduling?
Aesthetic Treatment (Body contouring, RF, laser, PRP)
IV infusion (NAD, Athletic Performance, Myers, Motherhood Infusion)
Wellness Injection (b12, Immune Boost, etc)
3
What Service?
Body Contouring
Facial RF Skin Tightening
PRP
4
WHAT TYPE OF CONSULTATION ARE YOU REQUESTING?
Aesthetics: (Consultation and Recommendations, Botox, Dermal Filler, Laser Facial, RF skin tightening, PRP Facial , Body Contouring, Stretch Marks, Acne, Laser Hair Removal)
IV Infusion
Wellness Injection (B12, MICC, NAD+, GLP-1, MICC etc.). NOT NEUROTOXIN (Botox) or Dermal Filler
Medical Weight Loss Consultation
Men's Health (Testosterone Optimization, low libido, erectile dysfunction)
Women's Health (Hormone Optimization /BHRT, low libido, vaginal rejuvenation)
Hair Restoration (PRP, Laser cap, Exosomes, Nutrafol, Microneedling, Copper Serums)
Lab Testing
Other
5
Date
Date
Month
Day
Year
6
ARE YOU A NEW PATIENT?
Yes
No, I've been seen at Creekside for this same service
No, I've been seen at Creekside, but for a different service
7
WHAT WELLNESS INECTION ARE YOU SCHEDULING?FOR NEUROTOXIN, please select back and choose AESTHETICS. This selection is for IVs and Injections
MICC (Or MICC Plus)
Weight loss injection training
Semorenlin
Semaglutide
Biotin
IV infusion
Other
8
WHAT LABS ARE YOU SCHEDULING?
Hormones : initiating treatment
Semorelin: initiating tretment
Hormones : Follow up
Semorelin: follow up
Thyroid
DNA: athletic testing
DNA: Cancer screening
DNA: Heart risk
Nutritional Profile
Unsure
Other
9
WHAT TYPE OF VISIT DO YOU PREFER?* This field is required.
Telehealth
At Creekside North (6635 W Central Avenue - McCord/Central)
10
WHICH SERVICE YOU ARE REQUESTING?
Facial Aesthetics
Body Contouring
Tattoo Removal
Laser Hair Removal
Hair Growth Treatments
11
ARE YOU REQUESTING MOBILE SERVICE OR YOUR TREATMENT AT CREEKSIDE NORTH?
Mobile Service
Creekside North
12
Sean Crayton RN, Director of Wellness Infusions, will reach out to you shortly to set up your infusion. Please provide your phone number.
Area Code
Phone Number
13
IS THERE A PARTICULAR SERVICE YOU ARE REQUESTING?
Unsure a particular service? Schedule a General Aesthetic Consult Here
Neurotoxin/Dermal Filler
Alma Clear Lift Laser Rejuvenation (Lunchtime Laser Facelift)
PRP facial rejuvenation
RF Skin Tightening (Cynosure Tempsure RF Treatment)
Microneedling: treats fine lines, scars, acne scars, pore size, overall skin tone and texture
Treatment of Melasma/Roseacea, Pigmentation, Vascular Lesions
Plasma Pen
Other
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