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Name*

First Last

Cell Phone Number*

Email*

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Appointment request*

Which area(s) are you looking to treat?*

Have you had this treatment before?*

Yes

No

Are you still experiencing any active acne?*

Yes

No

What are you looking to treat?*

Browns (sun damage/pigmentation)

Reds (facial veins/broken vessels)

Melasma

Tone and texture

What area are you looking to treat?*

Face

Chest

Back

Hands

Have you had Botox or similar before?*

Yes

No

Have you had dermal filler before?*

Yes

No

If yes, when was your last treatment?*

Have you had this treatment on this area before?*

Yes

No

If yes, when and what was your last treatment?*

What are your areas of concern?*

Forehead lines

Crow’s feet

Brow lift

Between my brows (11’s)

Under eyes

Lines above lip

Chin dimpling

Bunny lines (nose creases)

Massators (facial slimming)

Massators (teeth grinding)

Down turned corners of the mouth

Neck lines and bands

What are your skin concerns?*

Texture

Scarring

Discoloration/Pigmentation

Acne

Fine lines/Wrinkles

Rejuvenation

Which areas are you looking to have treated?*

Upper abdomen

Lower abdomen

Double chin

Back or bra fat

Love handles

Arms

Inner thighs

Outer thighs

Banana roll (crease under buttock)

Above the knee

Other

What areas are looking to treat?*

Abdomen

Buttock/Glutes

Love Handles/Obliques/Flanks

Biceps/Triceps

Thighs

Calves

Which area are you looking to treat?*

Nose

Chin

Forehead

Cheeks

Full face

Other

What are your areas of concern?*

Lips

Cheeks

Tear Toughs (under eye)

Temple Hollowing

Nasolabial Folds (lines from nose to mouth)

Marionette Lines (lines from mouth to chin)

Jawline

Chin

Vertical Lip Lines (smoker's lines)

Hand Rejuvenation

Please check as many as you want

Which area(s) are you looking to have treated?*

Facial areas

Bikini area

Legs

Arms

Underarms

Chest

Back

Shoulders

Stomach

Other

What are you looking to treat?*

Fine Lines/Wrinkles

Texture/Tone

Acne Scars

Surgical Scars

Pigmentation

Melasma

What areas are you looking to treat?*

Face

Chest

Back

Hands

Other

What are your areas of concern?*

Lip volume

Lip definition

Smoker's line

What are you looking to treat?*

Fine Lines/Wrinkles

Texture/Tone

Acne Scars

Pigmentation

Melasma

What area are you looking to treat?*

Face

Chest

Other

Which areas are you looking to have treated?*

Abdomen

Love handles

Thighs

Buttock

Above the knee

Arms

Other

What are your areas of concern?*

Smile lines

Edges of my mouth are turned down

Upper line

Eyes

Jowls or Jawline

Forehead lines

Crows feet

Chest

Other

Do you have any metal/surgical implants in your body (including copper IUD)?*

Yes

No

Have you had treatment before?*

Yes

No

Are you currently using Rogaine (Minoxidil)?*

Yes

No

If yes, when was your last treatment?*

Is your hair loss/thinning from normal ageing?*

Yes

No

This consultation is for clients/patients with ageing hair loss concerns similar to your mother or father would have and not for a diagnosis of other hair loss concerns; itchy or red scalps; alopecia areata or patchy hair loss or medical conditions affecting your scalp.

How would you describe your hair loss?*

Decreasing

Stable

Increasing

In what areas would you describe your hair loss?*

Hair Line

Top

Back

All over

At what age did you first begin to notice your hair loss?*

I am interested in the...*

Buy 2 receive 1/2 Free syringe

Buy 3 receive 1 Free syringe

Not sure

How tall are you?*

What is your current weight?*

NOTE: MicroPen micro-needling preferred days can be Mondays and Wednesdays only. Appointment times are from 8:30am - 12:30pm only.

Are you wanting treatment same day as your consultation?*

Yes ($100 deposit required)

No

Are you wanting treatment same day as your consultation?*

Yes

No

Preferred Date*

MM slash DD slash YYYY

Preferred Time*

Your Date of Birth*

DD slash MM slash YYYY

How did you hear about us?*

Other

Great! Enter their name to take advantage of our referral program*

* Referral program details

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Victoria Park Medispa Winnipeg

932 Grosvenor Ave. Winnipeg

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