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O Shot® Consultation Online

The O Shot® Consultation Online is a simple questionnaire that is submitted to our Doctors to see if Face Doctors has a solution that is right for you. It is obligation free and absolutely confidential.

Our Doctors will respond within 24 hours to your submission from your given email address. For a comprehensive consultation please contact Face Doctors to make an appointment.

* Indicates required field

How did you hear about this site? *

Internet Search Advertisement Friend Other

Face Doctors Website. O Shot® Consultation Online *

Yes

If Other please specify: *

Name *

First

Last

Age *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

What areas would you like to improve? *

Sexual Function Vaginal Appearance Urinary Function Reduced Urinary Incontinence Increased Personal Confidence Other

Please explain in further detail what your concerns are, and what you want to achieve *

Past Medical and Surgical History *

NIL Active Skin Infections Acute or Chronic Infections Active HSV, HPV. Prophylaxis Anticoagulants Blood Thinning Medications Autoimmune Disorders Diabetes Heart Disease Haemotological Disorders Hypertrophic Keloid Scarring Hypersensitivity to Topical Anaesthetics Immunosuppression Inflammatory Skin Disorders Genitourinary Cancer Genitourinary Disease Gynaecological Surgery Liver or Kidney Disease Platelet Disorders ITP PDS Pregnancy Other

If yes please explain. *

Past Sexual History of relevance. If None please write NIL *

Current Medications. If none please write NIL. *

Allergies. If none please write NIL. *

Have you taken any of the following in the last 2 weeks *

Aspirin Anti-inflammatories Voltaren-Diclofenac Nurofen or Naproxen Fish Oils or Omega 3s None of the above

Smoker. Note smoking has an adverse affect on all PRP treatments. *

Yes No

If yes, how many per day or week? *

Book an appointment. *

Yes, please call me. Yes, please email me. I would like more information.

Newsletter sign up *

By submitting this form you will be signed up to the Face Doctors Clinic Newsletter. We respect your privacy and you can unsubscribe at anytime.

Submit

Your personal details will remain confidential and not be disclosed to any third parties. You have the right to view, change or delete this information on request. This questionnaire is not comprehensive, and does not replace a full history, and physical examination and further information may be necessary on follow up. Due diligence will be exercised for making a thorough assessment.

Book For Auckland Clinics

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Auckland Choose Location *

Remuera Howick Manukau Head Office (No Clinic)

Ideal date and time *

Treatments Required *

Or Email belinda@facedoctors.co.nz

Submit

Book For Northland Clinics

* Indicates required field

Name *

First

Last

Email *

Phone Number *

NORTHLAND CHOOSE LOCATION *

Warkworth Marsden Cove Whangarei Kerikeri Doubtless Bay

IDEAL DATE AND TIME *

TREATMENTS REQUIRED *

Or Email facedoctorsnorthland@gmail.com

Submit

Please note this does not confirm your booking. We will get in touch with you to confirm your appointment time.
By submitting this form you will be signed up to the Face Doctors Clinic Newsletter. We respect your privacy and you can unsubscribe at anytime.
Please note we have allocated client parking, all unauthorized vehicles may be clamped or towed at owners expense. Clamping proceeds will be donated to monthly charity of our choice.

Sign up to our newsletter

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Name *

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Last

Email *

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O Shot® Consultation Online

Book For Auckland Clinics ​

Book For Northland Clinics

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Book For Auckland Clinics