Receive A Virtual Consultation
First Name:
Last Name:
Phone Number:
E-mail Address:
Age:
Height:
< 5'0"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'5" >
Weight(lbs):
Procedures:
Select a Procedure
Kybella
Laser Hair Removal
SculpSure Fat Removal
Microblading
ZO Skin Health
Profound
Microdermabrasion
Facials
Microneedling
Wrinkle Treatment
BOTOX®
Juvederm
TempSure Envi
Cellulite Treatment
Fractional Co2 Laser Resurfacing
Brow Tinting and Shaping
NovaLash Extensions
Peels
Dermaplaning
Miradry
Vaginal Rejuvenation
Other
For all body procedures please upload a photo of the body exposed from the neck to the knees. We will need a total of 3 pictures (front, side and back). For all facial procedures please upload a total of 3 photos (front and both sides).
Maximum File upload Size is 500 MB.
Photo Submission (Front):
Photo Submission (Side):
Photo Submission (Back/or Side):
Medical History:
HIPAA ACKNOWLEDGEMENT
Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold Advanced Aesthetics Med Spa, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.
By checking this box, I acknowledge my understanding of the HIPAA Policy and agree with its contents.