QWO Patient Interest Survey April 2021

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* 1. My contact information:

Name

Email Address

Phone Number

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* 2. What is the best time to call you to schedule a consultation and discuss our new QWO treatment in more detail?

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* 3. We have 4 QWO Providers in the MedSpa, do you have a preference on a provider?

Christy Craig, NP (Has a Spanish Speaking Assistant)

Heidi Fell, RN (Has a Spanish Speaking Assistant)

Lauren Ramos, RN

Michi Scholeter, RN (Spanish Speaking Provider)

I have no preference on provider

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* 4. In the past I have attempted to do what to help with my cellulite:

Loose Weight

Cellfina®

Creams and Lotions

Exercise

Carboxytherapy

endermologie®

Radiofrequency

Liposuction

Mesotherapy

Supplements

Nothing

Other (please specify)

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* 5. I am near my ideal weight

No, I need to loose weight

Yes, I'm at my ideal weight

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 6. I would say have I have how many dimples on my buttock:

Small Amount (1 - 5)

Medium Amount (5 - 10)

Large Amount (10- 15)

More than 15 dimples

I don't want to share

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* 7. Bruising is very likely with the QWO treatment, I am:

I am ok with bruising anytime, I don't care

I am ok with bruising, but I will plan my treatment after a vacation/event I have coming up

I am not ok with bruising

Other (please specify)

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* 8. Using this grading scale what you say is your grade of cellulite:

Grade 0 - None
No dimples or evident cellulite

Grade 1 - Almost None
Few dimples that are mostly superficial in depth

Grade 2 - Mild
Several dimples, of which most are shallow in depth

Grade 3 - Moderate
Many dimples, of which most are moderate in depth

Grade 4 - Severe
A lot of dimples, with some of more severe depth

I'd rather not answer

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* 9. How much is QWO? For your 3 treatments the cost of QWO is $3,375. We have 2 launch promos going on, which one are you most interested in?

50% OFF My Treatment
This launch promo is for a full photo release from the patient. Treatment will be paid for in-full, $3,375, at no discount at their first appointment and savings ($1,687.50) will be refunded after the patient has completed their 3 treatments and taken their after photos. Approximately 90 days after the first treatment. Refund is forfeited if the patient does not return for their after photos or chooses to no release their photos.
*Limited to 4 patients

25% OFF My Treatment
This launch promo do not require a photo release. Instant 25% OFF savings as we launch QWO at ACPS, $2,531.25
*Limited to 8 patients

I'm not certain