Cosmetic Service Request


Full Name *

Date of Birth *

New Patient? *

What are you interested in? *
IPL LaserPelleve Skin TighteningBotoxObagi Skin Care SystemLatisseIdeal Protein Weight Loss

What are your concerns? *
AcneEyes (sagging, dark spots)Hair RemovalHyper-pigmentation (age/sun spots)Large PoresMelasma (spotty skin)Vascular (spider veins)Wrinkles (facial)Short/Thin eyelashesSkin Tightening (elasticity)Weight Gain/Loss

What is your skin tone? *
PaleLightMediumDarkVery Dark

When would you like to schedule your appointment? *

*Please note this does not secure an appointment time. We will contact you to confirm your appointment*

When is your general availability? *
Weekday AMWeekday PMWeekend AMWeekend PM

Email *

Phone *

Questions or Comments




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  • The Urgent Care

    113 Belle Terre Blvd, LaPlace
    LA 70068 . (985)359 -2273

    148 Wall Blvd, Gretna,
    LA 70056 . (504)393-2273

  • Hours

    Weekdays: 8:30am - 8:00pm

    Weekends: 8:30am - 5:00pm

    Open Holidays!

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