Mesotherapy Questionnaire

Mesotherapy/Lipodissolve is the process of microinjections of medications into target body area(s) to dissolve fat and / or Cellulite.  To make sure you are a suitable candidate fill out the questionnaire as accurately as possible

I do not have any of the following conditions

  • Any kidney disease
  • Chronic Liver disease
  • Any general obesity
  • Insulin dependent diabetics
  • History of stroke
  • History of recent cancer
  • History of blood clots
  • On multiple medications for heart disease
  • Hepatitis, liver disease
  • Immunodeficiency Disorder
  • Bleeding disorder
  • Fibromyalgia
  • Lupus
  • Pregnancy or breast feeding
  • Pregnancy within the last 6 months

Unfortunately if any of the above conditions apply you may not be an ideal candidate for this type of treatment

   
Gender? Male Female
   
I have undergone plastic surgery

YES NO

 

If yes what procedure(s)

Name:
please provide first and last name.
   
Email:
   
Confirm Email:
   
Address:
   
City:
  State: Zip:
Daytime Phone:
(or best # to call)
   
Alt Phone:
   
Best time to be reached:
   
Procedure Requested:
   
I would like more info on:
(check all that apply) 		Botox®- smooth wrinkles
Restylane®- Fill in wrinkles
Juvéderm- Fill in wrinkles
Permanent Makeup
TCA Peels- erase wrinkles-even skin tone
IPL Photofacial- Treat rosacia, sun damage
Mesotherapy/Lipodissolve
   

Age:
   
Height:
   
Weight:
   
Area of concern: Abdomen
Saddle Bags
Thighs- inner
Thighs-outer
Love handles
Bra Strap
Back
Neck
other
   
How did you hear about Medical Aesthetics Inc.
   
Additional comments, questions or concerns:
   

I’m ready to schedule my $25 Mesotherapy/Lipodissolve consultation.  I’m aware that this fee can be applied to any MAI service.
YES NO

 

I’m not ready to schedule my consultation, but want to submit my information to enter the MAI® monthly drawing giveaway for $250 OFF any MAI® service
YES NO
 
We will contact you shortly to schedule your consultation.
   
 

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