Request Appointment

Name

Date of Birth (required)

Phone (required)

Email (Please check box below for news & updates to be notified of upcoming promotions). (required)

What are your aesthetic concerns or goals? (required)

How soon would you like to book? (required)

Please confirm Houston location (required)

Yes

Do you agree to a provider exam prior to treatment (Texas Law)? (required)

Yes

Are you pregnant or nursing? (required)

Yes NO

List current medications (required)

List known allergies (required)

List past surgeries (required)

List know conditions (required)

List past cosmetic treatments (required)

Would you like to apply for financing? (required)

Yes No

Do you understand no additional guests or children are allowed at the appointment? (required)

Yes

Do you understand and agree to our appointment policy listed below??
(required• A non-refundable deposit of $50+ is required to reserve any treatment or appointment. • Reschedule requests must be made at least 72 hours in advance to avoid forfeiting your deposit. • Rescheduling within 48 hours of the appointment will require a new deposit to be paid. • Cancellations made less than 24 hours before the appointment will require a new deposit to rebook, or the full service fee must be paid at the time of booking. • No-shows or missed appointments will result in the forfeiture of your deposit, and you will be unable to rebook the missed appointment unless the full service fee is paid at the time of booking. • All deposits are non-refundable and will be forfeited if you do not attend your scheduled treatment or appointment without prior notice.

Yes

Disclaimer (required)
Text Message Marketing Consent.Checking this box is my consent to receive phone calls, text messages and emails about my appointments, reminders, and patient care from AgelessRx. I understand that this consent is not a condition of purchasing any goods or services, I can opt out at any time, message/data rates may apply, and opting-in includes acceptance of our Privacy Policy and Terms of Service.

Yes