Consultation Request

WELCOME TO BEAUTOLOGIE!
Thank you for your interest in Beautologie Medical Aesthetics & Wellness! 
Gathering this information from you is the first step in the consultation process! By completing this form, we will have all the information we need to help you have an informative virtual or in-office consultation with a member of our team.
We can't wait to meet you!
Please tell us a little about yourself.
Your Name*
.
Date of Birth*
E-mail Address*
by entering your email address, you consent to email communication
Cell Phone*
By providing my contact information to Beautologie, I acknowledge and give my explicit consent to be contacted via SMS and receive emails for various purposes, which may include marketing and promotional content. Message and data rates may apply. Message frequency may vary. Reply STOP to opt-out. Reply HELP for more help.
How did you hear about Beautologie?*
Please feel free to describe in detail in "Other"
What is your friend's or family member's name if someone referred you to us?
Please include their first and last name. We won't let them know you contacted us but would love to send them a small gift for their referral of our newest patient.
What procedures are you interested in?  Check all that apply.
Which medical aesthetics procedures are you interested in? Check as many as you'd like.*
Wrinkle Relaxers (Botox, Dysport, others...)
Fillers (Restylane, Juvederm, Sculptra, others...)
Laser hair removal
Laser tattoo removal
Face skin tightening/resurfacing/peels
Cellulite reduction
Non invasive body contouring(CoolSculpting/Cooltone/Venus Freeze)
Morpheus8
Non-surgical buttock augmentation
Medical grade skincare (Obagi/Latisse, etc...)
Ink/inkless scar or stretch mark camouflage (available exclusively in Bakersfield)
Medical weight loss (Semaglutide, Wegovy, Ozempic, B-12) (available exclusively in Bakersfield)
IV Therapy (available exclusively in Bakersfield)
Supplements
Other:
*Medical Aesthetics services are currently available in Bakersfield, Fresno and Newport Beach exclusively.
Are you currently pregnant or breastfeeding? *
When would you like to have the procedure done?*
I have a specific date in mind
ASAP (the soonest date you have available)
In the next 3 months
In the next 6 months
In the next 12 months
Other:
How were you planning on paying for the procedure?*
Cash or Credit Card
I have a Care Credit or Alphaeon Card
I NEED TO apply for financing
I have a loan or alternate method of payment arranged
Other:
Choose your antipated payment method (as many as you like).
Please tell us in your own words what you would like to achieve with this procedure or procedures you have selected.
Thank you! Let's prepare for your Consultation appointment.
Choose from a Virtual appointment via Zoom or book at the office with a member of our team. 
What type of consultation would you like?*
Virtual Zoom Consultation with a member of our team
In-office consultation with a member of our team
I am not sure, please give me a call.
We are currently offering complimentary zoom or in-perosn consultations.
What is your preferred language to have your consultation?*
English
Spanish
Which location do you prefer for your Medical Aesthetics and/or Wellness treatment(s)?**
Bakersfield
Newport Beach
*Medical Aesthetic services are exclusively available in Bakersfield and Newport Beach.
Which day of the week works best for your consultation appointment? Check as many as you'd like.
Monday
Tuesday
Wednesday
Thursday
Friday
What time of day works best for your consultation appointment? Check as many as you'd like.
9:00 AM - 12:00 PM
12:00 PM - 3:00 PM
3:00 PM - 6:00 PM