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Win Botox For-a-Year Registration & RSVP Holiday Party Sale
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First Name
*
Your answer
Last Name
*
Your answer
Phone Number
Your answer
E-mail
*
Your answer
Preferred Contact
*
Email
Phone
Both
Other:
Date of Birth
*
MM
/
DD
/
YYYY
Please select procedures that you may be interested in.
*
Botox Cosmetic or other Neuro-modulator
Fillers
Voluma, Vollure, Volbella
Facial Contouring
Lip Augmentation
Lip Line Treatment
Skin Rejuvenation
Laser Resurfacing or Peels
Micro-needling, Radiofrequency for skin rejuvenation
Rosacea/Broken Blood vessels on face
PicoSure Tattoo Removal
O-shot/Wow shot (improves urinary incontinence and sexual arousal)
Eyelid Lift - Upper
Eyelid Lift - Lower
Advanced Lift (Facelift for jowls, jawline or neck)
Rhinoplasty
Chin Augmentation
Cheek Augmentation
Otoplasty (Ears)
Breast Augmentation
Liposuction
Mommy Makeover
Tummy Tuck
Vein Treatment
Breast Lift
Browlift
Hair Restoration (Non-surgical or SmartGraft Transplant)
PRP (Platelet Rich Plasma)
Emsculpt muscle building and fat loss (Abs, Buttocks, thighs,calves, biceps or triceps)
Emsella (nonsurgical pelvic floor tightening for urinary leakage)
Alma Duo (Improve erectile function in men and sexual arousal in women)
Hormone Replacement Therapy for Men & Women
Other:
Required
Please describe your interest in addressing any of the above concerns.
Your answer
Please include my name in the "Win Botox for-a-year" drawing.
*
Yes
No
Optional Questions
Select any special upcoming occasions?
Wedding
Birthday
Anniversary
Reunion
Divorce
Vacation
Nothing special
I'm just finally ready
Other:
What is the general timeframe that you might be interested in considering treatment.
ASAP
Spring 2022
Summer 2022
Fall 2022
Winter 2022
Other:
Clear selection
Is your family/significant other aware of your cosmetic concern(s)?
Yes
No
Maybe
Clear selection
Does your family/significant other support your desire for cosmetic surgery or enhancement?
Yes
No
Maybe
Clear selection
Please check any fears you have regarding surgery/medical procedures:
Anesthesia
Surgical Outcome
Opinions of others
Unsuccessful past procedures
Pain
Recovery Time
Complications
Natural-looking results
Current medical issues
Other:
Please check the potential opportunities having a procedure/surgery will provide for you:
Improved self-esteem
Improved self-confidence
Advancement in career/career change
Getting married
New relationship opportunities
Correction of cosmetic flaws
Physical appearance reflect mental image of self
Increased comfort with intimacy
Life event, i.e.: child’s wedding, school reunion
Other:
What are your preferred Social Media "channels"
Facebook
Instagram
Snapchat
YouTube
Twitter
Tick Tock
I dont use any social media
I only use social media for my work/business
Other:
Please share any other questions or concerns that you have at this time.
Your answer
If you would you like to share this with a friend please include their name and email below.
Friend Name
Your answer
Friend Email
Your answer
Thank you and we look forward to seeing you on November 20, 2021! More details will follow.
The Party and Sale are from 9 am to 1 pm. Online shopping will begin on Black Friday!
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