We can’t wait to see you for your Lips, Lines & Wine Consultation! Please complete the form below at least 24 hours PRIOR to your scheduled appointment time. If you haven’t scheduled your appointment yet, give us a call at 309.362.0390.

NOTE: If you are an existing patient for Medical Aesthetic services and have previously consulted with Laura or Megan, you may call us directly to schedule your appointment at 309.362.0390

MedSpa Virtual Consult Intake

  • Personal Information

  • Date Format: MM slash DD slash YYYY
  • Personal Health History

  • Please include and list all topical medications in addition to oral medications.
  • Skin Care & Concerns

    Please select all that apply:
  • Select Your Consultation Options

  • Please select if you would like to have your Injectable consultation in-person at Senara or Virtually via videoconferencing. Your $50 deposit secures your appointment, and can be used towards future medical spa treatments.
  • Consent and Payment

  • I acknowledge that I consent to consultation and/or treatment at Senara. I understand that the information I provided in this form is for the purpose of providing medical advice and I have answered accurately to the best of my knowledge at the time of completion. It is my responsibility to update my service provider of any changes to my medical status or any medications taken prior to receiving treatment. It is understood that Senara's programs are specialty services and do not have responsibility for your comprehensive medical care.
  • $50 Prepaid Deposit

    The consultation fee of $50 will be deposited to your account and can be used towards future medical spa treatments. The deposit also guarantees your appointment per our 24 hour cancellation policy.
  • $0.00
  • American Express
  • Please click submit to complete your registration.

    Note: DO NOT DOUBLE CLICK or click multiple times to avoid possible duplicate charges. One of our front desk staff members will call you to schedule your appointment time within 24 business hours after receiving your request with deposit.
  • This field is for validation purposes and should be left unchanged.