Service By Appointment Only

Monday - Friday 9:30 AM - 6 PM

Saturday 10 AM - 3 PM

Sunday Closed

Laser Hair Removal
Palm Beach Gardens, FL 33410

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Getting to Know You Survey

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)

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!

About

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Medical Aesthetic Procedures

Acne Therapy

Age Spots / Sun Damage

Cherry Angioma Removal

Electrolysis Hair Removal

Skin Resurfacing

Skin Tag Removal

Wrinkle Reduction

Skin Tightening

Non-Invasive Fat Reduction

Collagen Induction Therapy

Stretch Mark Reduction

Laser Procedures
CANDELA Laser Hair Removal
CANDELA Photo Rejuvenation

Skin Treatments
Diamond Microdermabrasion
Microneedling
VascuTouch
Electrolysis
Specialty Facials
Chemical Peels

Renew Laser & Aesthetics

3450 Northlake Blvd

Suite 105 B

Palm Beach Gardens, FL 33403

(561) 255-0272

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Getting to Know You Survey

Laser Procedures CANDELA Laser Hair Removal CANDELA Photo Rejuvenation Skin Treatments Diamond Microdermabrasion Microneedling VascuTouch Electrolysis Specialty Facials Chemical Peels

Hours of Operation Mon.- Fri. 9:30 AM - 4:30 PM Saturday 10:00 AM - 12 PM Sunday Closed *By appointment only.

Laser Procedures
CANDELA Laser Hair Removal
CANDELA Photo Rejuvenation

Skin Treatments
Diamond Microdermabrasion
Microneedling
VascuTouch
Electrolysis
Specialty Facials
Chemical Peels

Hours of Operation
Mon.- Fri. 9:30 AM - 4:30 PM
Saturday 10:00 AM - 12 PM
Sunday Closed
*By appointment only.