Returning Botox, Dermal Filler & Hyperhidrosis patients

Name*
First Last
Phone*
cell phone preferred
Email*
Treatment Request*
- BOTOX® Cosmetic
- BOTOX® for Underarm Sweating
- BOTOX® for Palm Sweating
- Dermal Filler Treatment
What areas are you wanting to treat? Please check as many as you want*
- cheek lift
- cheek volume
- smile lines
- edges of my mouth are down turned
- lip volume
- lip definition
- smoker's line
- temple sinking or hollowing
- lower lid hollows or tear troughs
- lower lids are sagging or baggy
- upper lids are sagging
- chin
- jowls or jawline refinement & definition
- stronger jawline
- forehead lines
- crows feet
- brow lift
- straighten nose
- earlobe creases
- other
If choosing BOTOX® Cosmetic, who would you like to perform the treatment?
- Dr Minuk (available Monday, Wednesday, Friday 8:30 AM-12:30 PM; Tuesday & Thursday 8:30 AM-4:45 PM)
- Carolyn Nurse Injector (available Tuesday and Thursday 8:30-4:00 PM)
- Diane Nurse Injector (available Monday – Friday)
Dr. Minuk and nurse injector Carolyn are available certain Saturdays, please call 204-957-7242 for available dates.
Preferred Date*
Date Format: MM slash DD slash YYYY
Preferred Time*
I wish to receive information on promotions, new treatments and procedures.
- Yes
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