Aesthetic & Vaginal Wellness Intake

Aesthetic & Vaginal Wellness Intake – InstaGyn

Personalized options for vaginal health, intimate wellness, facial aesthetics, and body treatments.
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Areas of Interest

This helps us tailor education and scheduling to your goals.
Which areas are you interested in learning more about? (Select all that apply)*

Vaginal/Intimate WellnessFacial AestheticsBody Contouring/SkinHair/Sweat/Other
Which area is your main focus right now?*

Vaginal/Intimate WellnessFacial AestheticsBody Contouring/SkinHair/Sweat/OtherI'm Just Exploring
Vaginal & Intimate Wellness

Intimate changes related to childbirth, hormonal shifts, or aging are common. Our goal is to provide comfortable, discreet, and evidence-based options tailored to you.
Which concerns are you experiencing or would like to discuss? (Select all that apply)

Vaginal drynessPain with intercourseVaginal laxity or loosenessDecreased sensationMild urinary leakageFrequent urinationCosmetic concern with appearanceElongated or asymmetric labiaI'm not sure, I'd like guidance
Have you gone through menopause?

YesNoUnsure
Have you tried any treatments for these concerns? (Select all that apply)

Over the counterPrescription or hormonal therapyPelvic physical therapyPrevious vaginal surgeryPrevious aesthetic procedureNo prior treatments
Facial Aesthetics
Which facial concerns would you like to address? (Select all that apply)

Fine lines/WrinklesAcne/Acne scarringDark spots/Sun spotsChin/Jawline concernsBlood vessels/RoseceaOther
Have you tried any prior facial aesthetic treatments? (Select all that apply)

Neuromodulators (Botox, Dysport, etc.)Dermal fillersMedical-grade skincareLaser or energy-based treatmentsI have not tried any treatments
Body & Skin Concerns
Which body or skin concerns apply?

CelluliteLoose skinCelluliteMuscle toningExcess weightHair removalExcess sweating (hands, feet, underarms)Scars from previous surgery
Have you tried any prior body or skin treatments? (Select all that apply)

Body contouring treatmentsLaser energy-based treatmentsWeight management programsI have not tried any treatments
Timing & Readiness
When are you hoping to address these concerns?*

As soon as possibleOver the next 1-3 monthsI'm just gathering information
Are you open to non-surgical treatment options?

YesPossiblyNot at this time
How should we follow up with you?
How would you prefer to receive more information?

TextEmailDiscuss during an in-person consultation
Additional Information
Is there anything else you’d like us to know or discuss?
Consent
I consent to receive non-marketing text messages and phone calls from InstaGyn Women’s Health & Aesthetics related to my inquiry. Message and data rates may apply. I may opt out at any time.*

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Aesthetic & Vaginal Wellness Intake – InstaGyn

Patient Information

Areas of Interest

Vaginal & Intimate Wellness

Facial Aesthetics

Body & Skin Concerns

Timing & Readiness

How should we follow up with you?

Additional Information

Consent