Skin · Hair · Facial Intake (PRF · Botox®) — Lumina Regenerative Sciences

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About you

So the clinic knows who you are and how to reach you.

First name*

Last name*

Email*

Mobile phone*

Date of birth*

City and state

Best way to reach you*

Text messagePhone callEmail

How did you hear about Lumina?

Google searchInstagramFriend or familyAnother providerOther

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What you’re interested in

Choose everything that applies — the consultation narrows it down.

Treatments*

PRF — facial rejuvenationPRF — under-eyePRF — hair restorationPRF — otherBotox® — forehead linesBotox® — frown linesBotox® — crow’s feetBotox® — other areaIV — skin / glowNot sure — I’d like guidance

What would you like to improve, and/or is there a goal or date you’re working toward?

When would you like to start?*

Within 2 weeksThis monthJust exploring

Also interested in the wellness side — energy, performance, digestion, or weight?

Yes — include it in my consultationNot right now

One physician, one plan. If yes, the doctor will bring the five key areas into the same visit.

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Aesthetic & treatment history

Helps the physician plan safely and set expectations.

Have you had Botox® or another neurotoxin before?*

NeverYes — within the last 6 monthsYes — longer ago

Which product, which areas, and any issues?

Other treatments you’ve had

Dermal fillersPRP or PRFLaser or microneedlingChemical peelsHair-restoration treatmentsIV therapyNone

Skin or hair concerns you’d like addressed

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Medical screening

These questions matter for PRF, neurotoxins, and IV therapy. Flagged answers are reviewed by the physician before anything is scheduled.

Do any of these apply to you?*

Neuromuscular condition (e.g., myasthenia gravis, ALS)Bleeding disorder or blood-thinning medicationHeart condition or high blood pressureKidney conditionLiver conditionDiabetesAutoimmune conditionG6PD deficiencySeizure disorderHistory of keloid scarringFrequent cold sores (HSV)Active infection or skin condition at a treatment areaNone of these

Allergies*

Botulinum toxin productsHuman albuminLidocaine or local anestheticsLatexMedications (list below)FoodsNone known

Allergy details

Current medications and supplements*

Pregnancy status*

Not applicableNoPregnantBreastfeedingTrying to conceive

Any procedures, vaccinations, or dental work in the last 4 weeks?

Do you smoke or vape?

NoOccasionallyYes

Affects healing after PRF.

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Anything else

Questions or context for the physician.

Anything you’d like the doctor to know before your consultation?

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Consent

Please confirm each statement.

The information I’ve provided is accurate and complete to the best of my knowledge.I understand this intake is not a diagnosis or a treatment plan, and that eligibility for any treatment is determined by the physician at a consultation.I understand that eligibility for PRF, Botox®, and IV therapy is decided by the physician after screening, and that some answers may mean a treatment isn’t recommended for me.I consent to be contacted by Lumina Regenerative Sciences by phone, text message, or email about my inquiry. Message and data rates may apply; reply STOP to opt out of texts.I have read the Privacy Policy and understand this form is submitted to the clinic’s secure intake system.

Submitted directly to the clinic’s secure, HIPAA-compliant intake system. This website does not store your answers.

Thank you.

Your Skin · Hair · Facial Intake has been sent to the clinic’s secure system. The clinic typically reaches out within one to two business days to schedule your consultation.

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