Schedule a Consultation

Please view our COVID policies here.

All cosmetic consultations are FREE!

Consultation times:
Tuesday:          8:30 am to 4:30 pm
Wednesday:    8:30 am to 4:30 pm
Thursday:        8:30 am to 4:30 pm
Friday:            8:30 am to 12:30 pm

Treatment times:
Monday to Friday : 8:30 am to 4:45 pm
Saturday 8:30 am to 4:30 pm

Name*
First Last
Phone*

cell phone preferred
Email*
Appointment request*
Preferred Date*
MM slash DD slash YYYY
Preferred Time*
Which area(s) are you looking to have treated?*
- facial areas
- bikini area
- legs
- arms
- underarms
- chest
- back
- shoulders
- stomach
- other
I am interested in the...*
- Buy 2 receive 1/2 Free syringe
- Buy 3 receive 1 Free syringe
- Not sure
Other*
Have you had treatment before?*
- Yes
- No
If Yes, When was your last treatment?*
When do you want to have you treatment with us?*
- Same day as my assessment?
- Within a week
- within one month
- 1-3 months
- not sure
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Have you had Botox or similar before?*
- Yes
- No
If Yes, When 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) massester muscles
- massators (teeth grinding) massester muscles
- down turned corners of the mouth
- neck lines and bands
When do you want to have you treatment with us?*
- Same day as my consultation
- Within 1 week
- 1-4 weeks
- Not sure
Have you had dermal filler before?*
- Yes
- No
If Yes, When was your last treatment?*
What are your areas of concern?*
- cheek lift
- cheek volume
- smile lines
- edges of my mouth are down turned
- lip volume
- lip definition
- smokers 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
Please check as many as you want
When do you want to have you treatment with us?*
- Same day as my consultation
- Within 1 week
- 1-4 weeks
- Not sure
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
- others
How tall are you?*
What is your current weight?*
Are you within 15% of your ideal weight? *
- Yes
- No
When do you want to have CoolSculpting? *
- as soon as possible
- within one month
- 1-3 months
- not sure
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Have you had treatment on this area before?*
- Yes
- No
If yes, when and what was your last treatment?*
When do you want to have this treatment with us? *
- as soon as possible
- within one month
- 1-3 months
- not sure
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
How many tattoos do you want removed*
- 1 tattoo
- 2 tattoo
- more than 2 tattoos
How old are your tattoos*
- less than 1 year
- 1-3 years
- more than 3 years
How big is your tattoo*
- larger than the size of your hand
- toonie size
- in between
Are you aware that it may take 6-12 treatments to remove a tattoo*
- Yes
- No
When do you want to have this treatment with us? *
- as soon as possible
- within one month
- 1-3 months
- not sure
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?
- Yes
- No
Have you had dermal filler before?*
- Yes
- No
If Yes, When was your last treatment?*
What are your areas of concern?*
- lip volume
- lip definition
- smokers line
When do you want to have you treatment with us?*
- Same day as my consultation
- Within 1 week
- 1-4 weeks
- Not sure
Have you had this treatment on this area before?*
- Yes
- No
If yes, when and what was your last treatment?*
When do you want to have you treatment with us?*
- Same day as my consultation
- Within 1 week
- 1-4 weeks
- Not sure
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Which area are you looking to treat?*
- Underarms
- Hands
- Feet
- Scalp
- Other
Have you had this treatment before?*
- Yes
- No
If yes, when and what was your last treatment?*
Do you have private insurance?*
- Yes
- No
If yes who is your provider*
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
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Which area are you looking to treat?*
- Nose
- Chin
- Forehead
- Cheeks
- Full face
- Other
Have you had this treatment on this area before?*
- Yes
- No
If yes, when and what was your last treatment?*
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Have you had this treatment on this area before?*
- Yes
- No
If yes, when and what was your last treatment?*
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Which area are you looking to treat?*
- Nose
- Chin
- Forehead
- Cheeks
- Full face
- Other
Have you had this treatment on this area before?*
- Yes
- No
If yes, when and what was your last treatment?*
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Which area are you looking to treat?*
- Chin
- Forehead
- Cheeks
- Full face
- Other
What is your of concern?*
- Wrinkles
- Scarring
- Texture
- Pigmentation
- Melasma
Have you had this treatment before?*
- Yes
- No
If yes, when was your last treatment?*
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Have you had treatments for this before?*
- Yes
- No
If Yes, When and what was your last treatment?*
When do you want to have you treatment with us?*
- Same day as my consultation
- Within 1 week
- 1-4 weeks
- Not sure
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
Which area are you looking to treat?*
- Chin
- Forehead
- Cheeks
- Full face
- Other
What is your of concern?*
- Wrinkles
- Scarring
- Texture
- Pigmentation
- Melasma
Have you had this treatment before?*
- Yes
- No
If yes, when was your last treatment?*
When do you want to have you treatment with us?*
- Same day as my consultation
- Within 1 week
- 1-4 weeks
- Not sure
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Which area are you looking to treat?*
- Under eyes
- Full face
- Other
What is your of concern?*
- Wrinkles
- Texture
- Rejuvenation
- Pigmentation
- Melasma
Have you had this treatment before?*
- Yes
- No
If yes, when was your last treatment?*
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
What are your hair “goals”?*
- Try to maintain current hair
- Try to stimulate hair growth
- Try to increase hair shaft density (thicker)
Are you currently using Rogaine (Minoxidil)?*
- Yes
- No
If yes, for how long?*
Are you currently using Finasteride/ Proscar/ Propecia for hair loss?*
- Yes
- No
Do you currently have or have you ever had a medical condition affecting your scalp?*
- Yes
- No
Have you ever had surgery of the scalp (including hair transplant)?*
- Yes
- No
If yes, please provide date*
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?*
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Which areas are you looking to have treated?*
- Full face
- Jaw line
- Eyes
When do you want to have treatment? *
- as soon as possible
- within one month
- 1-3 months
- not sure
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
Which areas are you looking to have treated?*
- abdomen
- love handles
- thighs
- buttock
- above the knee
- arms
- other
When do you want to have treatment? *
- as soon as possible
- within one month
- 1-3 months
- not sure
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Have you reviewed our Pricing Guide online?*
- Yes
- No
What treatment are looking to do?*
- EM:abs
- EM:butt-Lift
How tall are you?*
What is your current weight?*
Are you within 20% of your ideal weight?*
- Yes
- No
What is your birth year?*
MM slash DD slash YYYY
Are you aware EMsculpt treatment program is 2 treatments a week 2 weeks for a total of 4 treatments for each area?*
- Yes
- No
Do you have in surgical metal implants in your abdomen or body?*
- Yes
- No
When do you want to have Emsculpt? *
- as soon as possible
- within one month
- 1-3 months
- not sure
Are you familiar with the 4 treatment package pricing for each area?*
- Yes
- No
Are you aware of our 0% financing?*
- Yes
- No
Would you like information on our 0% financing?*
- Yes
- No
Cosmetic Surgery Request*
NOTE: MicroPen micro-needling preferred days can be Mondays and Wednesdays only. Appointment times are from 8:30am - 12:30pm only.
Consultation with Dr. Giuffre preferred date
- November 17, 2021
- December 15, 2021
- January 12, 2022
- February 9, 2022
- March 9. 2022
- April 6, 2022
- May 4, 2022
- June 1, 2022
- June 29, 2022
- July 27. 2022
- August 24, 2022
- September 21, 2022
- October 19. 2022
- November 16, 2022
- December 14, 2022
Note: Dr. Giuffre is only available from 12:15 to 4:45.
Your Date of Birth
DD slash MM slash YYYY
I wish to receive information on promotions, new treatments and procedures.
- Yes
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