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Expert Laser Hair Removal & Advanced Skincare in Palm Beach Gardens, Florida
BOOK NOW (561) 255-0272
ABOUT
Meet Ashley
Policy & Instructions
Patient Forms
Frequently Asked Questions
Why Candela is the Best Laser
HAIR REMOVAL
Laser Hair Removal
Electrolysis
Waxing
SKIN TREATMENTS
Photo Rejuvenation
Cherry Angioma
Skin Tag Removal
Microneedling Collagen Induction
Clinical Facials
OxyGeneo
Enzymes + Micropeels
Diamond Dermabrasion
Purifying Back Treatment
RF Skin Tightening
Cellulite + Lymphatic Massage
Non-invasive Lipolysis
ORDER NEOVA
PUBLISHINGS
CONTACT
Getting to Know You Survey
First name
Last name
Email
Where are you located? Please specify (City, State, Country)
Code
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Phone
Are you filling out this survey for yourself or on behalf of another person?
Please Choose
Please identify specifically how you found us or the name of who referred you.
What are your main goals for seeking Functional Nutrition Counseling?
Do you have any known health or medical conditions or diagnosis that I should know about in helping you to find the best care? If yes, please explain.
What have you tried so far to address your goal? (Diet, testing, cleanses, a specific therapy, etc.)
Which of the following items are currently in your diet in any amount: (Select all that apply)
Dairy
Gluten (wheat, wheatberries, durum, semolina, spelt, farina, rye, barley)
Grains
Eggs
Soy
Coffee
Soda Beverages
Caffeinated Tea
Processed Foods
Fast Food
Nightshades (tomato, eggplant, peppers and white potatoes)
Tree Nuts (almonds, brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pie nuts, pistachios, walnuts)
Peanuts
Sesame
Fruits
Sugar (refined sugar, cane sugar, sweets, desserts, candy, etc.)
Fish (bass, cod, flounder)
Crustacean Shellfish (crab, lobster, shrimp)
Oils (Canola oil, vegetable oil, sunflower oil, soybean oil, cottonseed oil, coconut oil, avocado oil, olive oil, etc.)
What percentage of your meals are currently home cooked?
*
0 - 15%
15 - 30%
30 - 45%
45 - 60%
60 - 100%
I am committed to working with indivduals who are dedicated to their health and ready to receive support on their individualized journey to health and healing. In two or three sentences, tell me something about yourself and/or your health history that will help me get to know you before we take any further steps to dig more deeply into the details of your concerns. When you're done, hit Submit!
Submit Survey
Your survey has been submitted! Once received and reviewed, you will receive a response. Thank you!
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