NameThis field is for validation purposes and should be left unchanged.Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!Name*Phone*Email* Injectables & Fillers Botox Injectable Daxxify Injectable Dysport Injectable Jeauveau Injectable Juvederm Fillers Radiesse Filler RHA Filler Sculptra Filler Bolatero Filler Restylane Fillers PRP Injections Xeomin Injectable AccuVein Technology Medical Weight Loss Permanent Makeup Non-Invasive BBL Facials Rosacea Chemical Peels Dermaplaning Body Sculpting Secret Duo by CUTERA Vitamin Infusions Vaginal Rejuvenation Laser Treatments for Spider Veins and Varicose Veins BHR, HRT & BHRT Excel V Laser by Cutera Exosome Treatment Treatment with Peptides Alma IQ™ Alma TED Hair Restoration Preferred Date MM slash DD slash YYYY Preferred TimeMorningAfternoonEveningMessage*SMS Opt-in or Opt-out Opt into receiving SMS Opt out of receiving SMS Consent* By submitting my information, I consent to receive SMS and/or email notifications from Cosmetica, Anti-aging, Aesthetic Lasers & Weight Loss Med Spa Clinic {for appointment reminders, promotional messages, offers etc}. Message frequency may vary. Message and data rates may apply. Text HELP to (650) 274-0944 or (408) 915-3880 for support. Reply STOP at any time to unsubscribe.*Consent* I agree to the following:A valid credit card and a $100 booking fee are required to reserve your appointment. The $100 will be applied as a credit toward any service you purchase. If no service is purchased, the $100 will act as your consultation fee. The $100 is non-refundable and will be kept as a cancellation fee if you cancel less than 24 hours before your appointment or as a no-show fee if you miss your appointment.
