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(832)387-5467
jsaesthetic.antiaging@gmail.com
Mon - Fri: 9:00 - 18:00 Sat 9:00 - 17:00

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Medical info
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Contact

Home
About
Services
Payment Plans
Medical info
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Contact

Home
About
Services
Payment Plans
Medical info
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Contact

Full name

Phone number

Place of birth

Date of birth

Age

Reason for consultation

How would you rate your skin type?

Normal Oily Dry Mixed I don't know

Skin Problems (If any)

Spots on the skin Acne Wrinkles Sensitivity Rosacea Others

If you select "Other", specify

Do you have any aesthetic concerns?

Have you had previous facial procedures?

Yes No

Do you use facial care products at home?

Do you have a known allergy to facial care products or ingredients or any type of food?

Do you have any restrictions or medical conditions that should be considered during facial procedures?

Are you pregnant or breastfeeding?

Yes No

How would you rate your overall satisfaction with your current facial appearance? (From 1 to 10, with 1 being very dissatisfied and 10 being very satisfied)

Additional comments or questions

Covid-19 Health Declaration

Name

Last Name

My body temperature is lower than 98.6°F / 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat, shortness of breath.

I haven´t been in close contact with a covid-19 patient in the last 14 days.

Initials

Date

I declare that the info I´ve provided is accurate & complete

Your moment is now, don't wait any longer and contact us!

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Contact Info

(832)387-5467
jsaesthetic.antiaging@gmail.com
16300 Katy Freeway suite 130 Houston Texas 77094

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