Name
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First Name
Last Name
Email
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Phone
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1. Do you feel younger and more vibrant on the inside than the reflection you see in the mirror?
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Yes – I still feel young, I just want my appearance to match.
No – I’m not feeling like myself lately and I know it shows.
2. Are you self-conscious about signs of aging – like wrinkles or sagging skin – that make you feel less confident?
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Yes – It’s time I did something about it.
No – I’m mostly okay with where I’m at right now.
3. Do you wish your skin had more of a youthful glow instead of looking dull or tired?
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Yes – I miss that fresh, radiant look.
No – I’m not concerned about my skin’s glow right now.
4. Have you noticed stubborn fat or weight gain (like a tummy bulge or love handles) that you can’t seem to get rid of, even with diet and exercise?
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Yes – It’s frustrating—I’m doing my part and still not seeing changes.
No – I feel okay with my body shape right now.
5. Would you be interested in a medically supervised weight-loss program or peptide therapy to help you finally reach your goal weight?
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Yes – Absolutely! I’ve been waiting for something that actually works.
No – I’m not ready to start anything new at the moment.
6. Do you ever find yourself comparing your appearance to younger women and wishing you could reclaim some of your younger look or figure?
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Yes – All the time. I just want to feel confident again.
No – I try not to compare, but I have my moments.
7. Have you ever tried any cosmetic treatments (like Botox, fillers, facials, etc.) before, or would this be your first time?
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Yes – I’ve done a few things before and I’m open to more.
No – This would be my very first time.
8. How soon are you looking to see noticeable improvements in your appearance?
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Right away – I’m ready to start now.
Within a few months – I’m planning ahead and exploring options.
Just exploring – I’m curious but not ready to commit yet.
9. Now that you have the means to do so, and after years of putting family first, do you feel it’s finally time to focus on you and invest in your own appearance?
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Yes – It’s long overdue. I’m ready to put myself first.
No – I’m still not sure if now is the right time.
10. Would you like a comprehensive makeover plan that combines multiple treatments – for example, facials for your skin, injectables for wrinkles, and body/laser treatments – to help you look and feel like the best version of yourself?
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Yes – I want a full transformation.
No – I prefer to keep it minimal for now.
11. Are you interested in long-term solutions to maintain your beauty – treatments that not only give results now but also help prevent future aging changes?
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Yes – I’m ready to invest in aging gracefully.
No – I’m okay with short-term fixes for now.
12. Have you noticed your cheeks or lips losing fullness over time, and would you like to restore that youthful volume?
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Yes – I miss that natural plumpness.
No – That hasn’t been a concern for me yet.
13. Do you have visible sun damage, dark spots, or uneven skin tone that you’d love to clear up for a more even, radiant complexion?
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Yes – I want clearer, more even-toned skin.
No – My skin tone isn’t really a concern for me.
14. Are you frustrated with unwanted hair (for example, on your legs, underarms, or face) and would you consider laser hair removal for a permanent solution?
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Yes – I would love not having to shave again.
No – I don’t mind managing it myself right now.
15. If you could change or improve one thing about your appearance in the next 6 months, what would it be?
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