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Call Today! 513-791-9474

Call Today! 513-791-9474

Book a Free Consultation

Thank you for your interest in our MedSpa! To request a free consultation on one of our aesthetic services, please fill out the form below. We’ll get back to you within a business day to schedule.

Free Consultation

Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Gender*
- Male
- Female
What is your height?*
What is your weight?*
Emergency Contact Name*
First Last
Emergency Contact Phone*
How did you hear about us?*
- Friend/Family Member
- Radio
- Internet Search
- Social Media
- Other
Friend or family member name*
What Radio Station?*
What were you searching for on the internet?*
What social media site/app did you see us on?*
What other source did you find Your Wellness Center*
Which service(s) will you be visiting our office for?*
- Hormones
- MedSpa
- Weight Loss
- IV Therapy
- Food Sensitivity Testing
- Sexual Medicine
What IV Therapy treatment are you interested in?*
- Get-Up-And-Go
- Recovery & Performance
- Myer's Cocktail
- Immunity
- Alleviate
- Inner Beauty
- NAD+ (250mg or 500mg)
- Vitamin C (Regular 5g)
- High-Dose Vitamin C (25g-75g)
- Amino Blend Injection
- B12 Injection
- Magnesium Injection
If interested in High-Dose Vitamin C, bloodwork and a provider consultation are required prior to starting treatment.
MedSpa Consultation Questions
What service(s) are you interested in?*
- Free Consultation
- Laser Treatment
- Injectables
- Facials
- Microneedling
- Chemical Peel
- Do you have other concerns?
Select all that apply
What skin condition(s) are you looking to treat?*
- Acne
- Anti-Aging
- Melasma
- Rosacea
- Sun Damage
- Scarring/Hyperpigmentation
- Tone/Texture
- Lines & Wrinkles
- Volume Loss
- Do you have other concerns?
Select all that apply
What is your skin type?*
- Dry
- Oily
- Combination
- Sensitive
- Normal
- Not Sure
Select any that apply
Weight Loss Progam
Have you ever been diagnosed with an Eating Disorder?*
- Yes
- No
Please answer: Type of disorder and diagnosis date?*
Reasons for Weight Loss*
Please list your top 5 reasons for weight loss
Medical History
Do you have a history (current or past) of cancer?*
- Yes
- No
Please answer: Type of cancer. Diagnosis date. Remission date.*
Are you pregnant*
- No
- Yes
- Possible
- N/A
Periods are*
- Regular
- Irregular
- None
- N/A
Hysterectomy*
- Full
- Partial
- N/A
Both Ovaries Removed*
- Yes - Both
- Yes - Only One
- No
Endometriosis*
- Yes
- No
Polyps*
- Yes
- No
Fibroids*
- Yes
- No
Date of Last Mammogram*
Date of Last Pap Smear*
Medical Conditions/Symptoms*
- Anemia
- ADD/OCD
- Anxiety
- Arthritis
- Asthma
- Bleeding disorder
- Cancer
- (CHF)Congestive heart failure
- COPD
- Coronary artery disease
- Depression
- Diabetes
- Diverticulitis
- Emphysema
- Gastritis
- Gout
- Heartburn/reflux
- Hepatitis
- Hiatal hernia
- High blood pressure
- High cholesterol
- High triglycerides
- HIV/AIDS
- H‐pylori
- Incontinence
- Irregular heart beat
- Irritable Bowel
- Kidney disease
- Kidney stones
- Liver disease
- Migraines/Headaches
- Polycystic Ovarian Syndrome (PCOS)
- Previous heart attack
- Prostate problems
- Pulmonary Edema
- Rheumatic fever
- Sleep apnea / snoring
- Stent placed
- Stomach ulcers
- Stress urinary incontinence
- Stroke/TIA/seizure
- Substance abuse
- Thyroid problems
- Tuberculosis
- NONE OF THE ABOVE
Medical Conditions/Symptoms - IV Therapy*
- Anemia
- ADD/OCD
- Anxiety
- Arthritis
- Asthma
- Bleeding disorder
- Cancer
- COPD
- Depression
- Diabetes
- Diverticulitis
- Emphysema
- Gastritis
- Gout
- Heartburn/reflux
- Hepatitis
- Hiatal hernia
- High blood pressure
- High cholesterol
- High triglycerides
- HIV/AIDS
- H‐pylori
- Incontinence
- Irregular heart beat
- Irritable Bowel
- Kidney disease
- Kidney stones
- Liver disease
- Migraines/Headaches
- Polycystic Ovarian Syndrome (PCOS)
- Prostate problems
- Rheumatic fever
- Sleep apnea / snoring
- Stomach ulcers
- Stress urinary incontinence
- Substance abuse
- Thyroid problems
- Tuberculosis
- NONE OF THE ABOVE
Medical History - IV Therapy*
- (CHF)Congestive heart failure
- Coronary artery disease
- Previous heart attack
- Pulmonary Edema
- Stent placed
- Stroke/TIA/seizure
- NONE OF THE ABOVE
"Yes" to any of these will require a consultation with the provider prior to treatment.
Do you have any of the following?*
- Protein-C Deficiency
- Protein-S Deficinecy
- Anti-Thrombin III Deficiency
- Factory 5 Liden Deficiency
- G6PD Deficiency
- NONE OF THE ABOVE
Do any of your family members have a history of blood clots or a blood clotting disorder?
- Yes
- No
Have you had a blood clot?
- Yes
- No
Have you had any surgical procedures?*
- Yes
- No
Please list surgical procedures*
Do you take any medications?*
- Yes
- No
Please list medications:*
Do you take any supplements?*
- Yes
- No
Please list supplements:
Do you have any allergies or sensitivities?*
- Yes
- No
Please list allergies or sensitivities:*
Such as foods, environment, medications, latex...etc
Family History
Do any of your family members have any medical conditions?*
- Yes
- No
Please list family medical history*
Such as strokes, heart attacks, stents, diabetes, hypertension, high cholesterol, blood clots, etc.
Hormone Information
Hormone Imbalance Checklist*
- Aches and pains
- Anxiety
- Apathy
- Autoimmune Illness
- Bone loss
- Brittle nails
- Chronic Illness
- Cold body temperature
- Decreased libido
- Decreased mental sharpness
- Decreased muscle mass
- Decreased stamina
- Decreased urine flow
- Decreased sexual satisfaction
- Depression
- Elevated cholesterol
- Elevated triglycerides
- Erectile dysfunction
- Fibromyalgia
- Foggy thinking
- General Fatigue
- Hair loss
- Headaches
- Hot flashes
- Inability to lose weight
- Increased urinary urge
- Infertility problems
- Irregular Menstruation
- Irritability
- Lack of motivation
- Morning Fatigue
- Night Sweats
- Oily Skin
- Painful intercourse
- Prostate problems
- Sleep disturbances
- Susceptible to infections
- Vaginal Dryness
- Weight gain in waist
- Other (list below)
- NONE OF THE ABOVE
Please list OTHER hormone imbalances*
Preferred Pharmacy
Preferred Pharmacy Name
Preferred Pharmacy Address
Street Address City State / Province / Region ZIP / Postal Code
Preferred Pharmacy Phone
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Contact

Address

7770 Cooper Road #8
Cincinnati, OH 45242

Phone

Phone: (513) 791-9474

Hours of Operation

Monday-Friday: 8:00 AM -4:30 PM

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