ABOUT
LASER
SKIN
FUNCTIONAL HEALTH
CLIENT FORMS
CONTACT

Expert Laser Hair Removal
in Palm Beach Gardens, FL

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!

Send your request for an office visit

First name

Last name

Phone Number

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Phone

(561) 255-0272

Address

3450 Northlake Blvd.

Suite 105

Palm Beach Gardens, FL 33403

Email

info.renewlaser@gmail.com

New Clients

Please Note: An in-office assessment is required for many services (Laser Hair Removal, Pigmentation Reduction, Collagen Induction and more). Consultation is $50 and may be applied toward the cost of service for same-day treatment.

Cancellation Policy

Once your appointment is scheduled, you will receive an automated text message 48 hours in advance to confirm your appointment. Please respond to this text message to confirm or cancel no later than 24 hours prior to your appointment to avoid a $50 Late Cancellation Fee. Unconfirmed appointments are forfeited. No Shows are charged the full cost of the service and must be paid before another appointment can be scheduled.

Payments Accepted

Getting to Know You Survey

Send your request for an office visit

​

Phone

(561) 255-0272

​

Address

3450 Northlake Blvd.

Suite 105

Palm Beach Gardens, FL 33403

Email

info.renewlaser@gmail.com