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Why Pay $120.00 - $140.00 . . . Elsewhere?
Just $83.00* 1st Visit Reg. $120.00
►If You Already Get Latisse From Us, Bring a Friend for Her
1st Latisse--and You Both Buy Latisse for Only $83.00*
►Just Apply the Solution to the Base of Your Eyelashes . . . to GROW!
Why Not Have REAL Eyelashes? Call 938-0190 NOW!
*$89.00/Each for Your 1st Latisse Prescription with Dr. Lee. If You Already Get Your Latisse from Us, Bring a Friend for Her 1st Prescription with Us--and You Both May Buy Latisse for ONLY $3.00/Each. Must Present This Cyber-Coupon Before Treatment, Not Valid With Any Other Offer, Expires 06/30/2010.
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Print & Complete This To Speed Your 1st Latisse Pick-Up To < 5 Minutes:
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HRWC Aesthetic Consultation Form, V-4
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Last Name:
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First Name:
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Address: City: ST: Zip:
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Age: Home Phone: Cell Phone:
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Occupation: E-Mail Address* @
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List Your Prescription Medications:_________________________________________________________
List Any Drug Allergies:__________________________________________________________________
Any Anti-Inflammatory (Aspirin, etc.) Meds? q YES q No Are You Pregnant? q YES q No
List Current Medical Problems:____________________________________________________________
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I Am Interested In:
q Eyelash length, fullness,
thickness, or darkness
q Latisse to Grow My Own Eyelashes
q BOTOX® Cosmetic
q Facial Folds & Wrinkles
q Juvederm Natural Wrinkle Filler
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I Am Interested In:
q Medically Supervised Weight Loss
q Zerona Body-Sculpting Laser
q Prescription Diet Medication
q Facial Fullness & Jowls
q Liver Spots/Age Spots
q Cellulite Dimpling
q Scar Treatments
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I Am Interested In:
q Spider Veins on Legs
q Teeth Brightening
q Thin Lips
q Dry Skin
q MicroDermabrasion
q Chemical Peels
q Other:
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Please Circle How You Heard About Us:
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Referred By:
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E-Mail from Horizon Ridge Wellness Clinic (HRWC)
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Google Search for:
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Website: HRWC Botox Latisse Juvederm
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Which Coupon Book?
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Other Source:
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HRWC Flat Screen TV in Reception Area
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____________________________________________________________________________________________
Printed Name Signature Date
*Listing here constitutes permission to E-mail Free/Special Discount Offers & VIP Invitations
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