Non-Surgical BBL Consultation Request Form

Non-Surgical BBL Consultation

Body Treatment Consultation Request Form

To determine if you are a good candidate for the Non-Surgical Radiesse Brazilian Butt Lift, please complete the Consultation Request form to receive a professional evaluation for our body treatment services.

Upload Requirements

Please click here to see example of how to take photos.

Send Image to NuremedyWellness@Outlook.com

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Full Name

First

Last

Date of Birth

Phone Number

concern date for

Email Address

Gender

Male
Female

Procedure of Interest

Area of concern (select all that applies):

Hip dips
Skin laxity
Lack of Projection
Lack of volume

Desired date for your procedure.

Date

Time

Date not guaranteed until consultation is completed.

Upload Images

Click or drag files to this area to upload. You can upload up to 6 files.

Follow These Photo Guidelines You can upload up to 768 MB Please provide 4 clear, well-lit photos wearing a thong undergarment. Be sure that the areas of interest are fully visible, so that our medical provider can complete a thorough assessment. Provide a total of 5 photos wearing undergarments. * 1 Full Body Frontal View * 1 Full Body *Back* View * 1 Full Body Left Side View * 1 Full Body Right Side View

Nu Remedy Wellness is your Apollo Beach,FL partner in achieving a healthier life. We offer medical weight loss, botox & fillers, and IV hydration services.

Body Treatment Consultation Request Form

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