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Aesthetics By Carefirst
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CONSULTATION FORM
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What treatment(s) did you receive during your visit?
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Xeomin (neurotoxin)
Dermal filler
RF Microneedling (SecretPro)
CO₂ Laser Resurfacing
TruSculpt iD (permanent fat reduction)
TruFlex (muscle sculpting)
Excel V+ Laser Genesis
Facial / Skin Treatment
Other (please specify)
Other Treatments:
How satisfied are you with the results of your treatment so far?
*
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
(from explain: with
How satisfied are you with the care and professionalism of your provider?
*
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Experience
How would you rate your overall experience with our office (from booking to checkout)?
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Excellent
Good
Fair
Poor
Did you feel well-informed about your treatment before it was performed?
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Yes, completely
Somewhat
No, not enough information
Was the environment (cleanliness, comfort, atmosphere) satisfactory?
*
Yes
No (please explain)
Please explain:
Open Feedback
Do you have any questions, comments, or concerns you would like to share with us?
Would you recommend us to a friend or family member?
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Yes, definitely
Maybe
No
May we use your feedback (anonymously) in our marketing materials or testimonials?
*
Yes
No
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