Customized Treatment Plan Pre-Assessment & Application
Virtual Pre-Assessment with Bianca Moon, PA-C
Welcome to the Soluma Aesthetics Pre-Assessment application form. Please submit this online aesthetic analysis form including photos and details of your aesthetic goals. After submitting the form you will be directed to a link for the online booking portal where you can pay your $25 booking fee. You will then be sent an automated email to register your account in the patient portal where you must fill out your medical history, consent forms, and questionnaires. Once received , our provider will return a customized treatment plan and pricing quote within 48 hours. Please note: This Virtual Pre-Assessment is not done during a specific face-to-face meeting time. It is done via TEXT only. It does not include time for a Q&A, however if you decide to go forward with the treatment plan you will have an opportunity for a Q&A during your in-person appointment for your scheduled treatment. We will discuss any questions or concerns you may have, then move right into the treatment.
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What services are you considering?
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Wrinkle Relaxers
Filler / Facial Balancing
PRF Gel
Sculptra / Radiesse
Sofwave Skin Tightening
PDO Threads
All of the above
Facial Rejuvenation Consultation - I'm not sure which of the above options I need
Skin Care Services (NOTE: This Virtual Pre-Assessment option is NOT available if you only want to discuss skin treatments such as chemical peels, microneedling, facials, skin care, or lasers. For skin services, a consultation must be done in-person only. If you book a Pre-Assessment and check off this option we will contact you to upgrade to an in-person consultation.)
Preferred Office Location
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Oviedo, FL
SoDo Orlando, FL (South Downtown)
Any Location
Preferred Start Date
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ASAP
3-6 Months from now
6-9 Months from now
1 Year from now
Once started, how soon would you like to see results?
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I need transformative results ASAP
Spaced out treatments within a 3-6 months
Within 6-9 months
Within 9-12 months
Have you had any aesthetic treatments?
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Yes
No
If yes, what treatments have you had and when were they received? If no, please write N/A.
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Have you had any previous facial surgeries? If so, what and when?
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What are your aesthetic goals?
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What are your favorite facial features?
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What is your ideal initial treatment investment?
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$700-$1000 (please note, this investment is typically for wrinkle relaxers only or skin treatments)
$1,000 - $3,000 (2-5 years younger - typical investment for partial facial balancing)
$3,000 - $5,000 (6-8 years younger - typical investment for full facial balancing or skin tightening)
$5,000 - $10,000 (9-10 years younger - typical investment for combination treatments)
How did you hear about us?
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Any additional information you’d like us to know?
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How would you prefer to schedule your initial appointment?
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Virtual Pre-Assessment: Please send my facial optimization plan via text. If I agree with the plan I will be scheduled an in-person appointment for my treatment. A Q&A is not provided during the Virtual Pre-Assessment, however my provider will answer all of my questions on the day of my treatment. ($25)
In-Person Consultation: I would like to schedule an In-person Get to Know you Session to begin my journey, discuss my treatment options, and have my provider answer all of my questions in-person. If I agree with the plan I will be scheduled on a separate day for my treatment or I may have my treatment done the same day if time allows. ($100)
(Front facing) Please upload photos in natural lighting, without makeup, and with a relaxed expression.
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30 degree angle right side. (Please upload photos in natural lighting, without makeup, and with a relaxed expression)
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Side profile right side. (Please upload photos in natural lighting, without makeup, and with a relaxed expression)
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30 degree angle left side. (Please upload photos in natural lighting, without makeup, and with a relaxed expression)
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Side profile left side. (Please upload photos in natural lighting, without makeup, and with a relaxed expression)
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By providing your email address, you consent to receive communications via e-mail regarding information about your appointment. Please check this box to continue.
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I consent to Email communication regarding my appointment or pre-assessment
By providing your phone number, you consent to receive communications via SMS regarding information about your appointment. Please check this box to continue.
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I consent to SMS communication regarding my appointment or pre-assessment
By providing your phone number and email address, you consent to receive communications via SMS and email regarding latest news or promotions. Please check this box to continue.
I consent to Email or SMS communication regarding latest news or promotions. I am aware I may opt out at any time.
Thank you for submitting your application to receive your customized treatment plan. To complete your application we will need to collect a booking fee first. When you hit “Submit” you will see a “Thank You” page with the online booking link. If you have not done so already, please visit the link there to pay the booking fee and confirm your Pre-Assessment. Please select “Virtual Pre-Assessment” - fee is $25. If you have already paid the booking fee we will contact you after submitting this form. We will NOT send you your treatment plan until you have paid the booking fee and submitted your required paperwork.
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I am aware that a booking fee is required. I will pay the fee at the online self-booking link provided after submitting this form.
I have already paid the booking fee through the online self-booking portal.
I have already paid the booking fee by phone through the Guest Relations Department.
The Virtual Pre-Assessment is done via TEXT only. To book, please go to the online booking link and select any time available on the calendar with the Virtual Assistant. This is only to start the process of the Pre-Assessment and it is NOT an appointment for a specific face-to-face meeting time (either in-person, zoom, or FaceTime) with our provider or assistant. After you have paid the Booking fee, submitted this form with pictures, AND completed all of the required paperwork, our provider will contact you with your treatment plan within 48 hours via TEXT only.
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I understand that the time chosen in the booking link is to start the process and not for a specific meeting time. I understand that the Virtual Pre-Assessment is done via TEXT only.
After paying the booking fee you will receive an email with a link to the patient portal. You must fill out your health history and questionnaires in order to receive your customized treatment plan. You must also submit your photos through this form. Once completed, you will receive your plan via text within 48 hours.
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I am aware that I must fill out all my required paperwork in the patient portal (questionnaires, consents, and medical history), and photos through this form, in order to receive my customized treatment plan. I will complete that as soon as possible. I have also attached my pictures to this form.
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