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Face & Skin
Anti Aging
DermaGlow™ IV – Glutathione
Glutathione Skin Brightening
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Spider Veins
Pigmented Lesions
Wrinkles & Fine Lines
Nail Fungus (Onychomycosis )
Skin Discoloration
Vaginal Rejuvenation
Vaginal Rejuvenation
Bikini Line Laser Hair Removal Treatment Jacksonville
Brazilian Laser Hair Removal Treatment Jacksonville
Laser Hair Removal
Unlimited Laser Hair Removal
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Hair Bumps (Pseudofoliculitis barbae)
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Remove Belly Fat
What You Must Know
What is PTHS
How & Why You Get PTHS
Signs & Symptoms of PTHS
How Your Body Breaks Down Fat
What is resistant fat
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What is LipoTranz®
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First Name
*
Last Name
*
Email
*
Phone Number
*
What services or treatments are you interested in?
LipoTranz / SpotLipo
Cosmetic Weight Loss
Remove Neck Fat
ClearBlu Laser Skin Care
Acne Treatment
FaceLift Without Surgery
Botox / Fillers
Chemical Peels
Hormone Replacement / Testosterone
Wellness Medicine
Natural Pain Management
Other
Other Treatment(s)
Appointment Date
*
Date Format: MM slash DD slash YYYY
Appointment Time
*
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HH
MM
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PM
Height
Weight
Do you have any chronic medical conditions?
*
Are you currently on any medications?
Have you had any type of surgery?
Have you had a c-section, hysterectomy, or any abdominal surgery?
Yes
No
Do you have stubborn resistant fat (fat that does not respond to diet & exercise)?
Do you have abnormal distribution of fat (Resistant fat in specific areas of your body)?
Do you have cellulite?
Do you have skin problems (loose skin, acne, dark spots, discoloration, faster skin aging, stretch marks, wrinkles)?
Do you suffer from depression / anxiety?
Do you have difficulty falling, and or staying asleep)?
Do you experience fatigue (Chronic lack of energy)?
Do you have low libido (lack of interest in sex, erectile dysfunction)
Do you have excess body hair (face, chest, bikini area)?
What diet are you currently following?
*
Do you currently exercise?
*
Yes
No
How often?
When was the last time you exercised?
*
Do you regularly get 6-8 hours of sleep?
Do you smoke cigarettes, pipe, cigars, or use smokeless tobacco?
Do you drink alcoholic beverages?
*
Goal Weight
*
Goal Pants Size
Goal Date
What's your goal?
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