Fill out the form below to schedule your cosmetic (medi-spa / surgical) consultation. We will call you back to confirm your appointment

First Name:*

Last Name:*

Email Address:*

Phone Number:*

Date of Birth:*

Insurance Type (ex. Blue Cross Blue Shield):

Request Service or Treatment*

Requested Date:

Requested Time:
 Morning Afternoon Either Morning or Afternoon

Specific Time:

Additional Notes:


Note: All cosmetic services are performed at our Peoria location.

*required