Returning Botox & Dermal Filler Clients
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Returning Botox & Dermal Filler Patients

Carolyn, RN Nurse Injector
Mon, Tues & Thurs 8:30 am – 4:30 pm
Wed 9:15 am – 1:15 pm

Danielle, NP Nurse Injector
Tues & Wed 8:30 am – 4:30 pm

Name*
First Last
Phone*
cell phone preferred
Email*
Treatment Request*
- BOTOX® Cosmetic
- 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
Preferred Date*
SATURDAY BOTOX TREATMENTS AVAILABLE:
MM slash DD slash YYYY
Preferred Treatment Provider*
I wish to receive information on promotions, new treatments and procedures.
- Yes
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Victoria Park Medispa Winnipeg

204-957-7242

932 Grosvenor Ave. Winnipeg

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