Booking Request Form - The French NP

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Are you a new or existing patient?* This field is required.
I am a new patient.
I am a returning patient.
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What is your name?* This field is required.
First Name
Last Name
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When is your birthday?* This field is required.
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What is your email address?* This field is required.
example@example.com
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What is the best phone number to reach you?* This field is required.
Please enter a valid phone number.
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Please select your preference:* This field is required.
In-Office Consultation
Virtual Consultation
7
Have you ever received treatment a from a medical spa? If yes, please specify treatments in the "Other" section.* This field is required.
Yes
No
Other
8
Which treatment(s) are you interested in?* This field is required.Please select all that apply.
Facial Balancing
Graceful Aging
Botox & Fillers
Bridal Consultation
Skin Consultation & Lasers
Lips
Laser Hair Removal
Brazilian Butt Lift
Vampire O-Shot (The Orgasm Shot)
Fat Melting
Hair Restoration
Host an Evening at The French NP
IV Vitamin Therapy
Other
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Please provide us with days/times that work best for your schedule:* This field is required. [Please be advised we will need to collect a consultation fee in order to complete your request.]
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Tell us more about what you are looking for:* This field is required.
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Would you like to receive a treatment on the day of your first consultation? If so, which treatment? :* This field is required.
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To finalize your request, we will need to collect a Consultation Fee of $150. * This field is required.This page will be redirected to an external link in order to collect your payment. Once your payment is successfully processed, our dedicated concierge will promptly reach out to you regarding upcoming appointments. After your appointment is booked, you will receive an email invitation with a temporary password to connect to our online patient portal. You must create an account and complete the required Health forms before your first visit. Merci Beaucoup.
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The requested form is for new patients only. If you are an existing patient, please contact our office at 617 615 6269 or email us at info@thefrenchnp.com* This field is required.
Merci.Thank you.
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