WALLA WALLA AESTHETICS
AND LASER SPA

(509) 540-5014
1605 SE Meadowbrook Blvd., Suite 5
College Place, WA 99324

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Home
About Us
- Team
- Mission
Conditions
Gallery
Services
Testimonials
Patient Forms
- Questionnaire
Contact Us

Questionnaire

30-SECOND QUESTIONNAIRE
COSMETIC MEDICAL TREATMENTS

Please take a few moments to answer the questions below. Your feedback will help us determine whether to offer our valued patients several of the country’s most popular non-surgical aesthetic procedure.

Your Name

Phone

Your Email

Best time to reach you

Would you be interested in Botox Cosmetic wrinkle removing therapy?

Yes No

If yes, which facial areas would you be interested in having treated?

Forehead Crow’s Feet Frown Lines (between the eyebrows) Other

Would you be interested in Restylane treatments?

Yes No

If yes, which facial areas would you be interested in having treated?

Smile Lines Vertical Lip Lines Lip Borders Marionette Lines (lines at the corner of mouth) Other

Would you be interested in IPL/Laser Hair Removal? (permanent hair reduction treatments are faster, more comfortable and more affordable than electrolysis and waxing)

Yes No

If yes, which areas would you be interested in having treated?

Face Underarms Bikini Line Legs Arms Back Chest Other

Would you be interested in receiving IPL PhotoFacial/Photorejuvenation treatments? (a series of safe, effective, non-invasive treatments designed to erase or reduce skin imperfections on either the face, neck, chest or other body areas)

Yes No

If yes, which conditions are you interested in having treated?