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Laser Consult
Fill out this form & our coordinators will be in touch to schedule a custom laser consultation with our providers!
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Name
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First Name
Last Name
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2
Phone Number
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Area Code
Phone Number
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3
Email
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example@example.com
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4
What are you looking to treat?
Please select all that apply
Skin Tightening
Hyperpigmentation
Scarring
Redness
Rosacea
Uneven Skin Texture
Wrinkles
Sun Damage
Pores
Acne
Hair Removal
Loose or Sagging Skin
DNA Damage
Freckles or Age Spots
Tattoo Removal
Get event-ready skin
Underarm Sweating
Other
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5
Have you had laser treatments before?
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6
Are you a Beauty Bank Member?
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7
What treatments and when?
Please list what laser treatments you have received.
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8
Do you have any additional comments/questions/concerns?
Let us know! We are here to assist you.
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