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Lajolee Aesthetics and Wellness
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Intake form
Help us serve you better
Name
*
Email address
*
Phone number
What services are you interested in?
Please select at least one option.
Botox
Hormone therapy
Testosterone therapy (TRT)
Peptides
Weight loss solutions
Advanced skin care (hydrodermabrasion)
Advanced skin care (microdermabrasion)
Have you received any of the following treatments before?
Please select at least one option.
Botox
Hormone therapy
Testosterone therapy (TRT)
Peptides
Weight loss solutions
Advanced skin care (hydrodermabrasion)
Advanced skin care (microdermabrasion)
What are your primary goals for seeking treatment?
Do you have any medical conditions we should be aware of? (If yes, please specify)
Are you currently taking any medications? (If yes, please specify)
How did you hear about us?
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Social media
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Referral
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Which service or services are you interested in?
Please select at least one option.
Botox treatments
Hormone therapy
Weight loss solutions
Initial consultation for $150
Follow-up consultation for $100
Additional questions or comments
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