Please fill up the form before booking your FREE Consultation.

Step 1

Full Name *

Date of birth *

Phone *

Email *

Choose a service: *

TRT Optimization

Peptide Therapy

Botox/Xeomin

IV Hydration

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Step 2

TRT & Peptide Candidate Survey

1. How’s your current energy & focus?

2. Do you exercise regularly?

3. Which issues are you experiencing? (please check all that apply)

4. What’s your #1 goal?

5. Have you ever had your hormone levels tested?

6. If you’re a good candidate, when would you like to start?

Step 2

Peptides Questionnaire

1. Have you ever used peptide therapy before?

If yes, which ones and when?

2. Do you have any chronic health conditions?

3. Are you currently taking any prescription medications, supplements, or hormones?

4. What are your main wellness goals?

5. Are you open to lab testing and a personalized peptide plan?

6. When would you like to start if you’re a good candidate?

Step 2

Botox Questionnaire

1. Have you ever had Botox or other neurotoxin treatments before?

If yes, when was your last treatment?

2. Do you have any allergies to botulinum toxin or related products?

3. Are you currently pregnant, breastfeeding, or planning to become pregnant?

4. Do you have any neurological or muscular disorders?

5. What areas are you most concerned about?

6. What is your main goal for Botox treatment?

Step 2

IV Hydration Questionnaire

1. Have you received IV hydration therapy before?

If yes, when did you have your last session

2. Do you have a history of heart, kidney, or liver conditions?

3. Are you currently taking any prescription medications or supplements?

4. Do you experience frequent dehydration, fatigue, or headaches?

5. What is your main goal for IV therapy?

Step 2

Laser Treatments Questionnaire

1. Have you received any type of laser treatment before?

If yes, when was your most recent treatment?

3. Are you currently using retinoids, Accutane, or other skin-sensitizing medications?

4. Do you have any active skin infections or conditions?

5. What areas would you like treated?

6. What is your main goal for laser treatment?

Step 2

RF Microneedling Questionnaire

1. Have you had microneedling or RF microneedling treatments before?

If yes, when did you last receive treatment?

2. Do you have any history of keloid scarring or poor wound healing?

3. Are you currently using retinoids, Accutane, or any skin-thinning medications?

4. Do you have any active skin infections, rashes, or cold sores?

5. What skin concerns are you hoping to improve?

6. What is your main goal for RF microneedling?

Thank you for sharing your responses!

Once you click SUBMIT, you’ll be redirected to book your FREE consultation.

We can’t wait to connect with you soon!

(323) 909-4349

Services

TRT Optimization Membership

Peptide Therapy Membership

Full Circle Men’s Wellness

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