Schedule a Consultation

Name*

First Last

Cell Phone Number*

Email*

Appointment request*

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?*

What are your skin concerns?*

Texture
Scarring
Discoloration/Pigmentation
Acne
Fine lines/Wrinkles
Rejuvenation

Which areas are you looking to have treated?*

What areas are looking to treat?*

Abdomen
Buttock/Glutes
Love Handles/Obliques/Flanks
Biceps/Triceps
Thighs
Calves

Which area are you looking to treat?*

What are your areas of concern?*

Please check as many as you want

Which area(s) are you looking to have treated?*

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
No

Preferred Date*

Preferred Time*

Your Date of Birth*

I wish to receive information on promotions, new treatments and procedures.

Yes

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