Returning Botox, Dermal Filler & Hyperhidrosis patients

Name*

First Last

Phone*

cell phone preferred

Email*

Treatment Request*

BOTOX® Cosmetic
BOTOX® for excessive sweating
Dermal Filler Treatment
Lip Filler With $150 Laser Savings Card

BOTOX® for excessive sweating*

BOTOX® for Underarm Sweating
BOTOX® for Palm (hand) Sweating
BOTOX® for Sole (feet) Sweating

What areas are you wanting to treat? Please check as many as you want*

I am interested in the...*

Buy 2 receive 1/2 Free syringe
Buy 3 receive 1 Free syringe
Not sure

Preferred Date*

SATURDAY BOTOX TREATMENTS AVAILABLE:

Preferred Time*

Dr Minuk: available Mon 8:30 am -12:30 pm | Tues, Wed, Thurs 8:30 am – 4:45 pm | Fri 8:30 am – 1:00 pm
Carolyn Nurse Injector: available Mon, Tues & Thurs 8:30 am – 4:30 pm

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Returning Botox, Dermal Filler & Hyperhidrosis patients

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