204-957-7242
Text Us
Returning Botox & Dermal Filler Clients
Book here
Schedule a
Consultation
Sign up for our
newsletter
Home
Contact
Treatments
Aesthetic Injectable Treatments
Dermal Fillers
Facial Rejuvenation
Lip Enhancers
Skin Boosters (Hydration)
Wrinkle Relaxers (Botox, Dysport, Nuceiva)
Body Treatments
CoolSculpting (Fat Reduction)
Double Chin & Neck Contouring
Emsculpt NEO & Edge (more muscle, less fat)
Hair Loss Therapy
Laser Hair Removal
Sculptra Butt Lift
Spider Vein Removal (Sclerotherapy)
Tattoo Removal
Pigmentation & Redness
BBL Photorejuvenation
Clear + Brilliant Laser
Facial Veins & Port Wine Stains
Fractional Laser (Resurfacing)
Skin Rejuvenation
Acne Scar treatments
Bela MD Microdermabrasion
Brown Spots, Pigmentation & Melasma
Latisse for Lashes
Microneedling
Microneedling with Radio Frequency
Non-surgical Face Lifts
Ultherapy & Ultherapy Boost – The Non-Surgical Face Lift
Promotions
SHOP
Sale/Promo's
Gift Cards
Hair Loss
Latisse
Skin Care | All Products
Skin Care by Brand
Skin Care by Concern
About
About Victoria Park Medispa Winnipeg
Our Skin Team
Newsletter
Privacy Policy
Price List
Schedule a Consultation
"
*
" indicates required fields
Name
*
First
Last
Cell Phone Number
*
Email
*
Enter Email
Confirm Email
Appointment request
*
-- Please Select --
Acne Scar Consultation
BBL Photorejuvenation Consultation
Botox/Dysport Consultation
Bela MD Microdermabrasion Consultation
Chemical Peel Consultation
CoolSculpting Consultation
Double Chin Consultation
Emsculpt NEO Body Sculpting Consultation
Facial Vein Consultation
Filler Consultation
Laser Hair Removal Consultation
Laser Resurfacing Consultation
Latisse For Eyelashes Consultation
Lip Filler Consultation
Microneedling Consultation
Microneedling with Radio Frequency Consultation
PRP Facial Rejuvenation Consultation
PRP Hair Growth Consultation
Sclerotherapy (Spider Leg Veins) Consultation
Skin Booster Consultation
Skin Care / Boutique Consultation
Skin Tightening Body Consultation
Skin Tightening Face Consultation
Tattoo Removal Consultation
Ultherapy Consultation
Wrinkle Consultation
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?
*
How big is your tattoo
*
Tiny (finger tattoo)
Small (size of a toonie)
Medium (size of a hand)
Large (size of a foot)
X-Large
Does your tattoo have colour?
*
Yes
No
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
*
-- Please Select --
Early Morning
Mid Morning
Late Morning
Early Afternoon
Mid Afternoon
Late Afternoon
Your Date of Birth
*
DD slash MM slash YYYY
Referred by a friend or relative?
Enter their name above to take advantage of our
referral program
.
Newsletter Opt-in
I would like to be notified about new products, treatments, and offers.
Subscribe to our newsletter for 15% off
your first online purchase!
CAPTCHA