Free Injectable Assessment

Name

First Name

Last Name

Phone Number *

(###)

###

####

What are your main areas of concern? (Select all that apply)

Forehead lines / frown lines

Crow's feet (lines around the eyes)

Lip enhancement or balancing

Smile lines (nasolabial folds)

Marionette lines (downturned corners of mouth)

Jawline contouring or definition

Chin enhancement or balancing

Tired or hollow under-eyes

Gummy smile

Facial asymmetry

Skin texture or acne scarring

General facial rejuvenation (not sure what I need yet)

Which treatment(s) are you interested in? (Select all that apply)

Neuromodulators (Botox / Dysport)

Dermal Filler

Microneedling

Chemical Peel

Facial Balancing

Have you had Botox, Dysport, or other neuromodulators before? *

Yes

No

Have you had dermal filler before? *

Yes

No

Have you ever been unhappy or disappointed with previous injectable treatments? (Select all that apply)

This will be my first time getting injectables

Results didn’t last as long as expected

I saw little or no improvement

My results looked uneven or asymmetrical

The results were too noticeable / unnatural

The treatment was more painful than expected

I felt it was overpriced for the results I received

I didn’t feel listened to or well-informed by my injector

I experienced bruising, swelling, or other side effects

I was happy with my previous treatments

Do you have any concerns, fears, or anxieties about treatment? (Select all that apply)

I don’t have any specific concerns

I’m nervous about needles

I’m worried about pain or discomfort

I’m concerned about bruising or swelling

I’m worried the results will look unnatural

I’m anxious about possible side effects or complications

I’m unsure what to expect during or after the procedure

I’m concerned about downtime (work, social events, travel, etc.)

I have travel plans soon after treatment

I’m scared of not liking the results