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3135 State Road 580, Suite 11, Safety Harbor, Florida 34695
813-602-0693
813-726-5695
eashe@pashenhealth.com
Mon-Fri : 9:00 am - 5:00 pm // Sat, Sun : Closed

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Step 1 of 11

What are your goals for this treatment?(Required)

Remove stubborn fat

Fit into smaller clothes

Boost self-confidence

Tighten up loose skin

Feel comfortable in a swimsuit

Other

Select all that apply

What area of the body are you wanting to improve(Required)

Abdomen

Buttocks

Chin/Neck

Back

Hips/Thighs

Chest (male)

Select all that apply

Has previous surgical work been done on these areas(Required)

Yes

It's complicated

Select one

Are you currently taking Semaglutide or Tirzepatide?

Yes

Do you have any of these medical issues(Required)

Diabetes

Insulin Resistance

Pancreatitis

Decreased Kidney Function

High Blood Pressure

Medullary Thyroid Carcinoma

Gallbladder Disease

Multiple Endocrine Neoplasia Syndrome Type 2

Other Medical Issues

No Medical Issues

Select all that apply

How many days per week are you physically active/exercising(Required)

select one

One those days how rigorous is your activity/exercise(Required)

Light

moderate

intense

Any questions about this treatment(Required)

What will my results look like?

How long will it take to see results?

What is the cost?

How many injections will I need?

What are the special discounts for new patients?

Other

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Name(Required)

First Last

Where do we send information to?(Required)

Phone

Text

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Email(Required)

Phone(Required)

Comments

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