Getting To Know You Survey

BOOK NOW (561) 255-0272

ABOUT
HAIR REMOVAL
SKIN TREATMENTS
NEOVA PRODUCTS
IMAGE SKINCARE
ARTICLES
CONTACT

First name

Last name

Where are you located? Please specify (City, State, Country)

Code

Phone

Are you filling out this survey for yourself or on behalf of another person?

Please identify specifically how you found us or the name of who referred you.

What are your main goals for seeking Functional Nutrition Counseling?

Do you have any known health or medical conditions or diagnosis that I should know about in helping you to find the best care? If yes, please explain.

What have you tried so far to address your goal? (Diet, testing, cleanses, a specific therapy, etc.)

Which of the following items are currently in your diet in any amount: (Select all that apply) * Required

Dairy

Gluten (wheat, wheatberries, durum, semolina, spelt, farina, rye, barley)

Grains

Eggs

Soy

Coffee

Soda Beverages

Caffeinated Tea

Processed Foods

Fast Food

Nightshades (tomato, eggplant, peppers and white potatoes)

Tree Nuts (almonds, brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pie nuts, pistachios, walnuts)

Peanuts

Sesame

Fruits

Sugar (refined sugar, cane sugar, sweets, desserts, candy, etc.)

Fish (bass, cod, flounder)

Crustacean Shellfish (crab, lobster, shrimp)

Oils (Canola oil, vegetable oil, sunflower oil, soybean oil, cottonseed oil, coconut oil, avocado oil, olive oil, etc.)

What percentage of your meals are currently home cooked? *

0 - 15%

15 - 30%

30 - 45%

45 - 60%

60 - 100%

I am committed to working with indivduals who are dedicated to their health and ready to receive support on their individualized journey to health and healing. In two or three sentences, tell me something about yourself and/or your health history that will help me get to know you before we take any further steps to dig more deeply into the details of your concerns. When you're done, hit Submit!

Your survey has been submitted! Once received and reviewed, you will receive a response. Thank you!

Request an in-office visit

First name(Required)

Last name(Required)

Email(Required)

Phone(Required)

Include country and area code. Example: 1-561-255-0272

What day of the week is best?(Required)

Do you prefer a morning or afternoon appointment?(Required)

What service(s) are you interested in?(Required)

Consultation

Laser Hair Removal

Electrolysis

Waxing

Photo Rejuvenation | Sun & Age Spots

Skin Tag Removal

Cherry Angioma Removal

Microneedling | Collagen Induction

Endospheres | Cellulite, Circulation, Lymphatic Drainage

IMAGE Clinical Custom Facial

Select the area(s) you are interested in treating:

Face

Lip

Chin

Jawline

Sideburns

Ears

Neck

Shoulders

Underarms

Upper arms

Lower arms

Hands | Fingers

Full arms

Back

Chest

Areola

Abdomen

Sagittal (Happy Trail)

Bikini Line

Brazilian

Glutes

Upper Legs

Lower Legs

Full Legs

Feet | Toes

BOOK NOW (561) 255-0272

Expert Laser Hair Removal in Palm Beach Gardens, FL

Contact

Call · Text (561) 255-0272

Location

3450 Northlake Blvd, 105

Palm Beach Gardens, FL 33403

By Appointment Only

Monday - Friday

Saturday

Sunday

10 AM - 5 PM

10 AM - 3 PM

Closed

Cancellation Policy

To avoid a cancellation fee, please call to cancel or reschedule no later than 24 hours prior to your appointment. Rescheduling is only offered after Cancellation Fee is paid in full.

Accepted Forms of Payment

All major credit cards, Apple Pay GPay, Zelle, Debit and Cash.